Percutaneous tibial nerve stimulation for the overactive bladder: A single-arm trial.

AIMS: We hypothesise that PTNS is a safe and effective treatment for OAB. Overactive bladder (OAB) is estimated to affect 11.8% of women worldwide, causing diminished quality of life. Lifestyle modifications, muscarinic receptor antagonist and beta-adrenoreceptor agonist remain the mainstay of treatment but are limited by their efficacy and adverse effects. Access to third-line therapies of intravesical botulinum toxin type A or sacral neuromodulation is limited by their invasive nature. Percutaneous tibial nerve stimulation (PTNS) has emerged as a non-invasive treatment option for OAB. METHODS: This study was a single-arm trial of women requesting third-line treatment for OAB. The primary treatment outcome was patient-reported visual analogue score (VAS) improvement of at least 50%. Secondary outcome measures were Urinary Distress Inventory Short Form (UDI-6) score and two-day bladder diary. Patients also provided feedback on adverse effects encountered. RESULTS: In the 84 women recruited, initial treatment protocol showed a success rate of 77.2% among those who completed treatment based on VAS, with a statistically significant improvement in mean UDI-6 score of 20.13 (P < 0.01, standard deviation: 12.52). Continued success following tapering protocol of 60.8% and a mean maintenance protocol of 14.2 months was achieved. No adverse effects were reported. CONCLUSION: The results from this study are in concordance with previously published literature on the effectiveness and safety of PTNS as a treatment modality for OAB. Further randomised controlled trials to evaluate the optimal treatment protocol are warranted to establish a standardised regime.

The effect of transvaginal prolapse surgery on anorectal function

Objective: Pelvic floor dysfunction can manifest as a spectrum including anorectal dysfunction, vaginal prolapse, and urinary incontinence. Sacrospinous fixation is a procedure performed by gynecologists to treat vaginal prolapse. The present study aims to evaluate the impact of transvaginal prolapse surgery on anorectal function. Materials and Methods: We conducted a retrospective review of patients undergoing sacrospinous fixation surgery for vaginal prolapse between 2014 to 2020. Those with anorectal dysfunction who had also been evaluated by the colorectal service preoperatively and postoperatively were included for analysis. These patients were assessed with symptom-specific validated questionnaires. The effect of surgery on constipation and fecal incontinence symptoms was analyzed. Results: A total of 22 patients were included for analysis. All patients underwent transvaginal sacrospinous fixation, and 95.4% also had posterior colporrhaphy for vaginal prolapse. There were a statistically significant improvements in the Fecal Incontinence Severity Index (FISI), the St. Mark's Incontinence Score (Vaizey), the embarrassment and lifestyle components of the Fecal Incontinence Quality of Life Score, the Constipation Scoring System, the Obstructed Defecation Score, and components of the Patient Assessment of Constipation Quality of Life score. Conclusion: Transvaginal prolapse surgery leads to a favorable effect on anorectal function, with improvements in both obstructed defecation and fecal incontinence scores in this small series. (AU)

Surgical repair and follow-up of chronic 4th degree obstetric perineal tear (total perineal defect) in 2 centres in eastern Africa.

INTRODUCTION AND HYPOTHESIS: Fourth-degree perineal tear occurs in up to 0.2% of vaginal deliveries. In limited resource communities, women often deliver in local villages without facilities to repair obstetric anal sphincter injuries. These fourth-degree tears heal by secondary intention and result in total perineal defects. The aim of the study is to present medium-term follow-up of a large number of women following repair of chronic fourth-degree tear. METHODS: Repairs of chronic obstetric fourth-degree tears were undertaken during surgical camps at Kagando Hospital, Uganda and Selian Hospital, Tanzania, from December 2013 to October 2019. Women completed Cleveland Clinic Incontinence Scores (CCIS) on admission (face to face) and during the 7-year follow-up period (via telephone). RESULTS: Two hundred fourteen women had medical history and CCIS completed on admission. The mean age at presentation was 33.9 years and mean duration of the condition was 8.9 years. Over a third of women stated they suffered social abandonment because of the unrepaired fourth-degree tear. Nearly 45% of women suffered the tear during the first vaginal delivery. At 1-year follow-up, 87% of 101 women scored 0 (perfect continence) and 94% of 66 women had perfect continence at 2 years. Forty-one births occurred during the follow-up period (32 vaginal deliveries) with two recurrences of fourth-degree tear. CONCLUSIONS: Follow-up in limited resource communities is challenging. Short- to medium-term results of women who had repair of total perineal defect (unrepaired fourth-degree obstetric tears) are encouraging.

Pelvic floor ultrasound findings in Ugandan women with obstetric fistula, unrepaired fourth degree obstetric tear, and pelvic organ prolapse.

BACKGROUND: While pelvic floor ultrasound is commonly utilised in high-resource locations, our understanding of pelvic floor characteristics in women suffering with obstetric fistula and unrepaired fourth degree obstetric tears in low-resource areas is limited. AIMS: This study aimed to assess the pelvic floor ultrasound characteristics of Ugandan women suffering with obstetric fistula, unrepaired fourth degree obstetric tears and pelvic organ prolapse, and determine whether obstructed labour resulting in obstetric fistula causes more levator muscle defects compared to parous women without a history of obstructed labour. MATERIALS AND METHODS: This was a prospective study in western Uganda assessing 82 women with obstetric fistula, unrepaired fourth degree obstetric tears and pelvic organ prolapse with a pelvic floor ultrasound scan. RESULTS: Demographic characteristics were significantly different, with women suffering pelvic organ prolapse being older and more parous. Hiatal area on Valsalva was significantly smaller in the obstetric fistula group (mean 21.45 cm2 ) compared to non-obstetric fistula group (unrepaired fourth degree obstetric tears and pelvic organ prolapse; mean 30.44 cm2 ); a mean difference of 9.0 cm2 (95% CI: 5.4-12.6 cm2 , P < 0.001). Overall, levator muscle defects were significantly more common in women with obstetric fistula (66.7%) compared to the non-obstetric fistula group (44.7%) with P = 0.048; however, there were no significant differences in complete levator muscle defects between obstetric fistula (28.6%) and non-obstetric fistula (23.7%). CONCLUSIONS: Increased hiatal area on Valsalva was noted in the non-obstetric fistula group compared to women with obstetric fistula; however, there were no differences in proportions of complete levator muscle defects.

Mental health screening in women with severe pelvic organ prolapse, chronic fourth-degree obstetric tear and genital tract fistula in western Uganda.

INTRODUCTION AND HYPOTHESIS: High levels of mental health dysfunction have been identified in women with genital tract fistula. The aim of this study was to use the General Health Questionnaire-28 (GHQ-28) to screen women in western Uganda with severe pelvic organ prolapse, chronic fourth-degree obstetric tear and genital tract fistula for risk of mental health dysfunction. METHODS: Women undergoing surgery for severe pelvic organ prolapse, chronic fourth-degree obstetric tear, and genital tract fistula were interviewed using the GHQ-28 to screen for the risk of mental health dysfunction. RESULTS: A total of 125 women completed the GHQ-28, including 22 with pelvic organ prolapse, 47 with fourth-degree obstetric tear, 21 with genital tract fistula, and 35 controls. Nearly all women with these serious gynaecological conditions were positive for the risk of mental health dysfunction. In the domain assessing symptoms of severe depression, women with fourth-degree obstetric tear and genital tract fistula scored higher than women with pelvic organ prolapse. CONCLUSIONS: A significant risk of mental health dysfunction was identified in women with severe pelvic organ prolapse and chronic fourth-degree obstetric tear. These rates are similar to the high rates of mental health dysfunction in women with genital tract fistula. Identification and management of mental health dysfunction in women with these conditions should be a priority.

Outcomes following surgical repair using layered closure of unrepaired 4th degree perineal tear in rural western Uganda.

INTRODUCTION: In many rural low-income countries, perineal tears at time of vaginal birth are not repaired at time of delivery. The aims of this study are to describe the surgical technique for management of the unrepaired 4th degree tear, performed without flaps, and short-term follow up on anal incontinence symptoms using a validated questionnaire. METHODS: Women presenting to fistula camps in western Uganda with unrepaired 4th degree tears were interviewed using the Cleveland Clinic Continence Score. Interviews were undertaken pre-operatively, at 4-6 weeks post-operatively and 12 months following surgery. Repair of the 4th degree tear was performed in layers, with an overlapping anal sphincter repair and reconstruction of the perineal body, without flaps. All women were examined prior to discharge. RESULTS: 68 women completed pre-operative Cleveland Clinic Continence Scores. Prior to surgery, 59 % of women complained of daily incontinence to solid stools. Over 70 % of women complained of restriction to lifestyle due to the unrepaired 4th degree tear. About 50 % of the women are rejected by their husbands because of the condition. Only 1 woman had wound breakdown on Day 2. At 4 to 6 weeks follow-up, 61 women were contacted and all reported perfect continence. CONCLUSION: This study highlights the hidden problem of unrepaired 4th degree tears in rural areas of low-income countries where most deliveries are undertaken in the village without professional health care workers. These tears have significant impact on quality of life and anal incontinence. Short-term outcomes following surgical repair using a layered closure are promising.

Treatment-seeking behaviour and social status of women with pelvic organ prolapse, 4th-degree obstetric tears, and obstetric fistula in western Uganda.

INTRODUCTION AND HYPOTHESIS: This study looks at a trilogy of women's health issues including severe pelvic organ prolapse, unrepaired 4th degree obstetric tears and obstetric fistula, all of which can cause significant suffering in the lives of women and their families. METHODS: Women undergoing surgery for severe pelvic organ prolapse, unrepaired 4th degree obstetric tears and obstetric fistulae, were interviewed to assess their perceptions of what caused their condition, subsequent impact on their social situation and sexual activity, and whether they had sought treatment previously. RESULTS: One hundred fifty women participated in the survey, including 69 undergoing surgery for genito-urinary fistula, 25 with faecal incontinence only (including 24 women with unrepaired 4th degree obstetric tears and 1 woman with an isolated rectovaginal fistula), and 56 women with severe pelvic organ prolapse. All groups of women were exposed to abandonment by their families with 42 % of women with genito-urinary fistula, 21 % with unrepaired 4th degree obstetric tear, and 25 % of women with severe pelvic organ prolapse rejected by their husbands. Most of the women had actively sought treatment for their condition with no success due to unavailability of treatment or misinformation. CONCLUSIONS: This study confirms the social stigma associated with obstetric fistula, however also highlights the social stigma faced by women suffering with severe pelvic organ prolapse and unrepaired 4th degree obstetric tears in western Uganda. There is an urgent need for education and training in obstetric management and pelvic organ prolapse management in such areas of limited resources.

Use of periurethral injections of polyacrylamide hydrogel for treating post-vesicovaginal fistula closure urinary stress incontinence.

AIMS: Following successful closure of obstetric genitourinary fistula, stress urinary incontinence (SUI) is a common and challenging problem. Despite many decades of various treatment options, the effective management of post-fistula SUI remains unresolved. This study aims to assess the feasibility of periurethral injections of polyacrylamide hydrogel, commonly used for urinary stress incontinence in non-fistula women, in women with post-fistula closure SUI. MATERIAL AND METHODS: Women with urinary incontinence following successful fistula closure were assessed to exclude detrusor overactivity and urinary residual volumes of more than 100 mL. The urethrovesical junction was identified and polyacrylamide hydrogel was injected through the periurethral skin and vaginal epithelium at three sites. RESULTS: Four women with post-fistula SUI were treated with polyacrylamide hydrogel injections. Three of the four women were dry post-operatively and remained continent at discharge. CONCLUSION: In the short-term, periurethral injections of polyacrylamide hydrogel appears to be a promising method to treat post-obstetric fistula urinary stress incontinence.

Biomechanical properties of graft materials employed for pelvic floor reconstructive surgeries.

PURPOSE OF REVIEW: Numerous biomaterials are currently used to augment pelvic organ prolapse reconstructive surgeries. Understanding the biomechanical properties of the raw and implanted graft materials may lead to improvements in biomaterial design and development. This summary aims to review recent assessments and advances in the understanding of vaginal tissues and synthetic graft materials profiles. RECENT FINDINGS: Numerous meshes have been assessed and compared for various biomechanical properties. There is now an emphasis on more relevant mechanical tests rather than only comparing loads at failure. Development of tests at physiological loads is important in achieving relevance of biomechanical data. Comparisons of partly absorbable with nonabsorbable meshes both preimplantation and postimplantation, have shown no difference in biomechanical properties, thus promoting the use of less permanent components in meshes. Potential factors contributing to mesh exposure are presented. SUMMARY: Biomechanical testing of synthetic graft materials is moving towards achieving data relevant to physiological loads and clinical conditions. Modeling research is required to understand these physiological loads, and create relevant measurements which can then be used when biomechanically assessing both raw and implanted grafts.

Classification of female genito-urinary tract fistula: Inter- and intra-observer correlations.

BACKGROUND: Currently, there is no accepted standardized classification for genital tract fistulae. Many classifications have been proposed previously, mainly based on anatomical locations. This is the first paper on inter- and intra-observer correlations using a recently published classification system based on fixed reference points. AIM: To assess intra- and inter-observer reliability of a new classification for genito-urinary fistula. METHODS: This is a prospective assessment of women with genito-urinary fistula. Women attending the Fistula Clinic in Ethiopia and Liberia were assessed by three fistula surgeons. The women were assessed in the outpatients and the fistulae were staged. In Liberia, where two surgeons were working together, inter-observer reliability was assessed. All women had the fistulae restaged in the operating theatre and intra-observer concordance was assessed. The clinicians were blinded to the outpatient results. RESULTS: A total of 119 women were recruited. All women had intra-observer assessment and had the fistula examined by the same clinician in the outpatients and in the operating theatre. Fifty of these women had inter-observer assessment with two clinicians assessing the same women. The results demonstrated that this classification system had high concordance in intra- and inter-observer reproducibility. CONCLUSION: The new classification for genito-urinary fistulae utilizing fixed reference points is a useful tool in describing fistulae. This study has shown that this classification produced consistency in description amongst different clinicians and also by the same clinician in a different consultation. This therefore allows more precise communication of clinical findings.

Biocompatible properties of surgical mesh using an animal model.

AIM: To study the biocompatibility of surgical meshes for use in pelvic reconstructive surgery using an animal model. METHODS: Eight different types of mesh: Atrium, Dexon, Gynemesh, IVS tape, Prolene, SPARC tape, TVT tape and Vypro II, were implanted into the abdominal walls of rats for 3 months' duration. Explanted meshes were assessed, using light microscopy, for parameters of rejection and incorporation. RESULTS: Type 1 (Atrium, Gynemesh, Prolene, SPARC and TVT) and type 3 (Vypro II, Dexon and IVS) meshes demonstrated different biocompatible properties. Inflammatory cellular response and fibrosis at the interface of mesh and host tissue was most marked with Vypro II and IVS. All type 1 meshes displayed similar cellular responses despite markedly different mesh architecture. CONCLUSIONS: The inflammatory response and fibrous reaction in the non-absorbable type 3 meshes tested (IVS and Vypro II) was more marked than the type 1 meshes. The increased inflammatory and fibrotic response may be because of the multifilamentous polypropylene components of these meshes. Material and filament composition of mesh is the main factor in determining cellular response.

Laparoscopic sacral suture hysteropexy for uterine prolapse.

This study aims to describe and review a new method of uterine conservation in pelvic reconstruction for women with uterine prolapse. This is a prospective study of women who have undergone laparoscopic sacral suture hysteropexy. Structured questions, visual analogue patient satisfaction score (VAS), and vaginal examination were undertaken. Follow-up was performed by non-surgical reviewers. From July 2001 until August 2003, a total of 81 women underwent laparoscopic sacral suture hysteropexy for uterine prolapse. At a mean of 20.3 months follow-up, 76 women (93.8%) were available for questioning and 57 (70.3%) attended for examination. Sixty-five women (87.8%) had no symptoms of pelvic floor prolapse, 54 women (94.7%) had no objective evidence of uterine prolapse, and 61 women (82.4%) were satisfied with their surgery (VAS > or = 80%). Laparoscopic sacral suture hysteropexy attaches the posterior cervix to the sacral promontory via the right uterosacral ligament. Follow-up data of laparoscopic sacral suture hysteropexy indicate it to be an effective method in the management of uterine prolapse.

Mental health screening in women with genital tract fistulae.

There is little information regarding the mental health status of women with genital tract fistulae in developing countries. The aim of this prospective observational study was to screen women at Dhaka Medical College Hospital, Bangladesh (December 2003 to June 2004), and Addis Ababa Fistula Hospital, Ethiopia (June to July 2004), with genital tract fistula for mental health dysfunction. Women presenting to the above institutions were screened using the General Health Questionnaire (GHQ-28) prior to fistula surgery. As the women were illiterate, the questionnaire was completed with the assistance of a medical officer, nurse or interpreter. The female staff members acted as controls. Sixty-eight women with fistulae and 28 controls completed the GHQ-28. Sixty-six of the 68 women with fistulae screened positive to probable mental health dysfunction compared with 9 of the 28 controls. We conclude that women with genital tract fistula are at high risk of mental health dysfunction. If the high rates of positive screening are confirmed on psychiatric evaluation, then the management of women with genital tract fistulas must include routine psychological/psychiatric assessment and treatment.