Pelvic organ prolapse management.

Pelvic organ prolapse describes the loss of support and subsequent descent of pelvic organs into the vagina. It is common, affecting up to 50% of parous women, and can be accompanied by a number of burdening symptoms. Prolapse has been thrown into the spotlight secondary to mesh-related complications. There are a number of effective treatment options to consider when managing pelvic organ prolapse and most do not require mesh. Patients' choice, comorbidities and likelihood of treatment success should be considered when making decisions about their care. Vaginal mesh surgery is currently on hold in the UK and even prior to this there has been a reduction both in the number of all prolapse surgeries and the number of women seeking surgery to manage their symptoms. This article reviews the current evidence for the management of pelvic organ prolapse, providing an update on the current state of mesh in prolapse surgery and summarises the key evidence points derived from the literature.

Is there an association between aspects of the metabolic syndrome and overactive bladder? A prospective cohort study in women with lower urinary tract symptoms.

OBJECTIVE: The aim of our study was to determine whether there is a link between aspects of the metabolic syndrome (MetS) and overactive bladder (OAB) in women with lower urinary tract symptoms (LUTS). STUDY DESIGN: A single-centre prospective study. We evaluated a cohort of consecutive women with LUTS attending a tertiary referral urodynamic clinic from October 2012 to January 2015. Obesity, diabetes, hypertension and dyslipidaemia were used as markers of MetS. OAB and detrusor overactivity (DO) were defined according to the International Urogynaecological Association/International Continence Society terminology. RESULTS: Eight hundred and forty women were enrolled. Three hundred and eight (36.6%) had normal weight, 260 (31%) were overweight and 272 (32.4%) obese. We identified 168 women (20%) with hypertension, 64 (7.6%) with diabetes mellitus, and 98 (11.7%) with dyslipidaemia. Seven hundred and four (83.8%) women were diagnosed symptomatically with OAB and 305 (36.3%) were diagnosed urodynamically with DO. Obesity (p<0.001) was the only independent predictor for OAB (OR 1.09, 95% CI 1.05-1.13) and DO (OR 1.06, 95% CI 1.03-1.08), respectively. CONCLUSION: Our study demonstrates a correlation between obesity and OAB/DO in female patients. However, other components of MetS do not appear to be associated with either OAB and DO. Weight reduction should be strongly recommended in women with OAB.

Sexual function after urinary incontinence surgery.

UNLABELLED: Urinary incontinence (UI) affects between 42 and 71% of women. Sexual dysfunction is prevalent in the general population, but in women with UI, the prevalence is greater (42-56%). This review assesses the effects of urinary continence surgery on the sexual function of women with UI. Stress UI is surgically mostly managed via Burch colposuspension or a mid-urethral sling. These operations are as effective as each other with regards to maintaining or improving in sexual function. One of the main risks of these operations are that urgency UI (UUI) may be exacerbated or arise de novo and this has been shown to decrease sexual function. Severe refractory UUI requires complex surgery, such as percutaneous sacral nerve stimulation (SNS) then augmentation cystoplasty or urinary diversion. SNS may improve sexual function by direct action on the pudendal nerve as well as improving incontinence. Urinary diversion and augmentation cystoplasty are procedures of last resort in women who are refractory to all other UUI treatments. The majority of women report no change or improvement in sexual function as the urinary diversion negates the requirement for incontinence pads and indwelling catheters. Deteriorated sexual function has also been described in up to 37.5%. Thirty percent of women undergoing urinary diversion would have liked more 'sexological' counselling. CONCLUSION: The majority of women enjoy maintained or improved sexual function after surgical treatment of UI. It is important to ensure women have appropriate pre-operative assessment and counselling so they may be advised of the risks of failed surgery including deteriorated sexual function.

National survey of perineal trauma and its subsequent management in the United Kingdom.

INTRODUCTION AND HYPOTHESIS: Perineal trauma affects approximately 350,000 women per annum in the United Kingdom (UK) and is associated with considerable morbidity. Symptoms are most severe following obstetric anal sphincter injuries (OASIS) compared with other grades of perineal trauma. The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines indicate that the rate of OASIS is 1 % of vaginal deliveries. In 2011, the RCOG implemented the "Maternity Dashboard" so that units could benchmark their performance against national standards of which OASIS is a component. Our primary objective was to establish the national rate of OASIS and audit variations in incidence and management of obstetric perineal trauma. METHODS: We carried out a questionnaire-based survey auditing national practice. Every UK maternity unit was contacted regarding perineal outcomes after all deliveries between January 2009 and January 2010. RESULTS: 215 of the 265 units in the UK responded (81 %). 692,259 of the 790,197 deliveries in the UK for the same period were sampled (88 %). 75 % delivered vaginally. The median national OASIS rate was 2.85 % (0-8 %). 20.2 % of women delivering vaginally had episiotomies; none were midline. 12.4 % of second-degree tears were not repaired in low-risk units compared with 5.9 % in high-risk units. 57.1 % of units used the perineal trauma classification of the RCOG. CONCLUSIONS: This study provides comprehensive data regarding the incidence and management of perineal trauma across the UK. Clinicians and policy-makers, both local and at the RCOG, can devise up-to-date realistic guidelines on the anticipated rate of OASIS and help to assess the compliancy of units with guidelines on the appropriate management of perineal trauma.

The value of vaginal packing in pelvic floor surgery: a randomised double-blind study.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to evaluate the effect of vaginal packing following pelvic floor surgery with regard to post-operative pain, bleeding and infection. This was a double-blind randomised study of women undergoing vaginal hysterectomy and/or pelvic floor repair at a tertiary urogynaecology unit. METHODS: The primary outcome of day 1 post-operative pain was assessed using the short-form McGill Pain score. Secondary outcomes were haematological and infective morbidity, evaluated using changes in full blood count, and cultures of midstream urine and high vaginal swabs. A transvaginal ultrasound scan to exclude pelvic haematoma was performed at 6 weeks in all women who underwent vaginal hysterectomy with or without a pelvic floor repair. RESULTS: In total, 190 women were recruited: mean age 58.3 years (27-91 years), mean body mass index 27.4 kg/m(2) and median parity 3. Women were randomised into the 'pack' (n = 86) and 'no pack' (n = 87) arms with no demographic differences between the groups. No statistically significant differences in the post-operative pain scores or secondary outcome measures were demonstrated. Incidence of haematoma formation (14.8 % no pack, 7.3 % pack, p = 0.204) was not statistically significant. There were three clinically significant complications in the no pack group and none in the pack group. CONCLUSIONS: This is the first study to examine pain in association with post-operative vaginal packing. There is no evidence to suggest that packing increases pain scores or post-operative morbidity. A trend towards increased haematoma and significant complications was seen in the no pack group. As vaginal packing does no harm and may be of some benefit it may be argued that packing should be recommended as routine clinical practice.