Transurethral Polyacrylamide Hydrogel Injection Therapy in Women Not Eligible for Midurethral Sling Surgery.

OBJECTIVES: This study aims to determine the effects of transurethral polyacrylamide hydrogel injection in patients considered ineligible for midurethral sling surgery. METHODS: In this prospective observational study, 81 patients received treatment with transurethral polyacrylamide hydrogel injection. Patients were considered ineligible for placement of a midurethral sling based on significant comorbidity (48%), 1 or more previously failed invasive treatments (16%), mixed urinary incontinence (27%), continuous incontinence (5%), or previous pelvic radiation therapy (4%). Longitudinal assessment of subjective treatment outcomes was performed using the validated Urinary Distress Inventory (UDI) and the Pelvic Floor Impact Questionnaire at baseline, 2, and 6 months. To deal with repeated measurements, mixed linear models were used to assess changes in the outcomes over time. RESULTS: There was a significant improvement in the overall UDI score from baseline to month 2 follow-up (FU) (P<0.001). No major differences between the month 2 and 6 FUs were observed. The largest difference in effect was observed for the irritative and stress subscales. Twenty-five patients (33%) requested a second injection at the month 2 FU visit. At month 6 FU, the UDI scores for patients having had only 1 injection were largely unchanged, whereas all UDI domains worsened further for patients having had a second injection at the month 2 visit. After the injection, there were 3 minor adverse events (3.7%) and no serious adverse events. CONCLUSIONS: In patients considered ineligible for midurethral sling surgery, transurethral injection with polyacrylamide hydrogel may alleviate urinary incontinence symptoms. Repeat injections did not improve outcomes in this complicated group of patients.

Transanal submucosal polyacrylamide gel injection treatment of anal incontinence: a randomized controlled trial.

INTRODUCTION: The efficacious and safe use of transurethral injections of polyacrylamide hydrogel (Bulkamid(®)) in women with stress urinary incontinence suggests that it may be suitable also for treatment of anal incontinence. We aimed to determine the effectiveness and safety of polyacrylamide hydrogel when used as a transanal submucosal bulking agent in women with anal incontinence. MATERIALS AND METHODS: Thirty women with a diagnosis of anal incontinence and a Cleveland Clinic Incontinence Score (CCIS) >10 were randomized to three different techniques of transanal submucosal injections using polyacrylamide hydrogel. Follow up was performed at 2, 6 and 12 months using CCIS and the Fecal Incontinence Quality of Life scale (FIQL). RESULTS: In all, 29 of the 30 women completed the follow up. Approximately half of the women requested a re-injection at the 6-month visit. The overall CCIS improved significantly from baseline (14.7. SD 2.5) to 1 year (12.4. SD 3.1) (p = 0.003). There was a significant improvement with regard to the occurrence of loose fecal incontinence (p = 0.014) but not for solid fecal incontinence (p = 0.28). At 1 year the FIQL domains of coping-behavior, depression, and embarrassment showed significant improvements (p = 0.012, p = 0.007 and p = 0.007, respectively). We recorded no adverse events related either to the injection technique or the biomaterial. There were no significant differences between the treatment groups in either CCIS or FIQL scores. CONCLUSION: Transanal submucosal injection of polyacrylamide hydrogel resulted in a modest although significant overall improvement in anal incontinence symptom scores with corresponding improvements in several domains of quality of life, regardless of injection volume.

Vaginal hysterectomy and risk of pelvic organ prolapse and stress urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: This study aims to determine the risk of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery related to mode of hysterectomy focusing on vaginal hysterectomy. METHODS: We performed a nationwide cohort study. Women exposed to hysterectomy on benign indications (n = 118,601) were compared to women unexposed to hysterectomy (n = 579,200). The outcome was defined as first occurrence of POP or SUI surgery. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs) using Cox proportional-hazards models. RESULTS: The greatest risks of POP (HR 4.9, 95% CI 3.4-6.9) or SUI surgery (HR 6.3, 95% CI 4.4-9.1) were observed subsequent to vaginal hysterectomy for pelvic organ prolapse. Having a vaginal hysterectomy for other reasons also significantly increased the risks of POP and SUI surgery compared to other modes of hysterectomy. CONCLUSIONS: Hysterectomy in general, in particular vaginal hysterectomy, was associated with an increased risk for subsequent POP and SUI surgery.

Impaired rectal sensation at anal manometry is associated with anal incontinence one year after primary sphincter repair in primiparous women.

PURPOSE: This study investigates the association between endoanal ultrasonography and anorectal manometry in relation to anal incontinence after primary repair of obstetric sphincter injury in primiparous, premenopausal women. METHODS: The study population of this nested case-control study comprised 108 women who had previously been part of a randomized controlled trial comparing immediate with delayed primary repair of obstetric sphincter injuries, and who had been evaluated by anorectal manometry and endoanal ultrasound 1 year after their repair. Twenty cases and 88 controls were defined. Cases were defined as having a score greater than 2 on the Pescatori incontinence scale. Controls had a score of 2 or less. Ten obstetric, 9 ultrasonographic, and 7 manometric variables were studied. RESULTS: Of the manometric variables, volume of first sensation and volume of first urge proved to be associated with anal incontinence at univariate statistical analysis. Volume of first sensation remained independently associated with anal incontinence after multivariate analysis. In addition, age, degree of tear, duration of second stage of labor, and a distal scar at ultrasound proved to be independently associated with anal incontinence. CONCLUSIONS: Impaired rectal sensation at anorectal manometry and a distal scar at endoanal ultrasonography are associated with anal incontinence 1 year after primary sphincter repair in primiparous women. Additional studies need to evaluate whether these findings are associated with increased risk of anal incontinence in women that are continent 1 year after primary repair.

Anal incontinence and bowel dysfunction after sacrocolpopexy for vaginal vault prolapse.

INTRODUCTION: This study aimed to determine the prevalence of bowel dysfunction and anal incontinence in relation to vaginal vault prolapse surgery in women hysterectomized on benign indications. METHODS: This is a case-control study where women having had sacrocolpopexy (n = 78) were compared with hysterectomized women without sacrocolpopexy (n = 233) using a bowel function questionnaire and the Cleveland Clinic Incontinence Score (CCIS). RESULTS: Sacrocolpopexy was performed on average 13.7 years (+/-11.1 SD) after the hysterectomy. Sacrocolpopexy was associated with an increased prevalence of rectal emptying difficulties (p = 0.04), incomplete rectal evacuation (p < 0.001), digitally assisted rectal emptying (p < 0.001), and use of enemas (p = 0.001). There was no overall significant difference in mean CCIS when comparing women having had vaginal vault prolapse surgery (CCIS = 2.78 +/- 4.1 SD) with those without (CCIS = 2.1 +/- 3.3 SD, p = 0.1) CONCLUSIONS: Abdominal sacrocolpopexy is associated with obstructed defecation but not anal incontinence when compared to hysterectomized controls without vaginal vault prolapse surgery.

Natural progression of anal incontinence after childbirth.

INTRODUCTION AND HYPOTHESIS: The aim of work is to study the natural progression of anal incontinence (AI) in women 10 years after their first delivery and to identify risk factors associated with persistent AI. METHODS: A prospective cohort study of 304 primiparous women with singleton, cephalic delivery giving vaginal childbirth in 1995. Questionnaires distributed and collected at delivery, 9 months, 5 years and 10 years after, assessing anorectal symptoms, subsequent treatment, and obstetrical events. RESULTS: Women, 246 of 304, answered all questionnaires (81%). Thirty-five of 246 (14%) had a sphincter tear at the first delivery. One hundred ninety-six of 246 (80%) women had additional vaginal deliveries and no caesarean sections. The prevalence of AI at 10 years after the first delivery was 57% in women with a sphincter tear and 28% in women, a nonsignificant increase compared to the 5-year follow-up. Women who sustained a sphincter tear at the first delivery had an increased risk of severe AI (RR 3.9, 95% CI 1.3-11.8). Neither age, nor subsequent deliveries added to the risk. Severe AI at baseline and 5 years after delivery were independently strong predictors of severe AI at 10 years (RR 12.6, CI 3.3-48.3, and RR 8.3, CI 3.9-17.8, respectively). CONCLUSION: Persistent anal incontinence 10 years after the first parturition is frequent and sometimes severe, especially if vaginal delivery was complicated by an anal sphincter disruption.

Risk factors for vaginal vault prolapse surgery in postmenopausal hysterectomized women.

OBJECTIVE: The purpose of this study was to identify risk factors for surgery of vaginal vault prolapse in hysterectomized postmenopausal women. DESIGN: We conducted a case-control study. The cases were 117 consecutive postmenopausal hysterectomized women who underwent vaginal vault prolapse surgery at Danderyd Hospital or Karolinska Hospital, Stockholm, between 1996 and 2005. Control participants were 326 age-matched, randomly selected, hysterectomized women with no vaginal vault prolapse surgery, identified from the Swedish Inpatient Register. For participants and controls alike, data on determinants were extracted from patients' records, the Swedish Inpatient Register, and self-report questionnaires. Data were analyzed using nonparametric statistics and logistic regression. RESULTS: The questionnaire was returned by 90 of 117 participants (77%) and 233 of 326 controls (71%). The mean age at response to the questionnaire was 72.8 (+/- 9.7 SD) and 71.3 (+/- 8.7 SD) years for participants and controls, respectively. In a multivariate analysis, the only predictors at a significant level were age at hysterectomy (odds ratio = 1.04, 95% CI: 1.004-1.08), prolapse or incontinence surgery before hysterectomy (OR = 2.8, 95% CI: 1.0-7.7), and prolapse or incontinence surgery before vaginal vault surgery (OR = 9.1, 95% CI: 3.6-23.4). CONCLUSIONS: Postmenopausal women with surgically managed pelvic floor disorders are at increased risk of developing vaginal vault prolapse subsequent to a hysterectomy.

Symptoms of anal and urinary incontinence following cesarean section or spontaneous vaginal delivery.

OBJECTIVE: The objective of the study was to compare the prevalence of incontinence disorders in relation with spontaneous vaginal delivery or cesarean section. STUDY DESIGN: Two hundred women with spontaneous vaginal deliveries only were compared with 195 women with cesarean deliveries only 10 years after first delivery. RESULTS: When compared with cesarean section, vaginal delivery was associated with an increased frequency of stress urinary incontinence (P = .006) and an increased use of protective pads (P = .008) as well as an increased frequency of fecal urgency (P = .048) and gas incontinence (P = .01). At multivariate regression analysis, mode of delivery showed no significant association with incontinence symptoms other than an increased risk for flatus incontinence in women with a history of obstetric anal sphincter injury (odds ratio 3.1; 95% confidence interval, 1.5 to 8.9). CONCLUSION: Incontinence symptoms are more common following spontaneous vaginal delivery when compared with cesarean section 10 years after first delivery. However, cesarean section is not associated with a major reduction of anal and urinary incontinence.

Effects of hysterectomy on bowel function: a three-year, prospective cohort study.

PURPOSE: This study was a prospective evaluation of the long-term effects of hysterectomy on bowel function using self-reported outcome measures on symptoms of constipation, rectal emptying difficulties, and anal incontinence. METHODS: In this prospective cohort study, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on bowel habits and anorectal symptoms preoperatively. Forty-four patients underwent vaginal and 76 abdominal hysterectomy. Follow-up was performed one and three years postoperatively. Data were analyzed by using multivariate regression and nonparametric statistics. RESULTS: The bowel and anorectal survey was answered by 115 of 120 patients (96 percent) after one year and 107 of 120 patients (89 percent) after three years. Abdominal hysterectomy was associated with increased anal incontinence symptoms at one-year (P < 0.01) and three-year follow-up (P < 0.01). Vaginal hysterectomy was not associated with increased anal incontinence symptoms at one year follow-up, although there was a significant increase in incontinence symptoms at the three-year follow-up (P < 0.05). Risk factor analysis indicated that a reported history of obstetric sphincter injury was correlated to an increased risk of developing posthysterectomy anal incontinence (odds ratio, 2.07; 95 percent confidence interval, 1.05-2.87; P < 0.05). There was no significant rise in constipation symptoms or rectal emptying difficulties in either cohort through the follow-up. CONCLUSIONS: Neither abdominal nor vaginal hysterectomy was associated with constipation, aggravation of constipation, or rectal emptying difficulties three years after surgery. Abdominal and vaginal hysterectomy was, however, associated with an increased risk of mild anal incontinence symptoms, and patients with a reported history of obstetric sphincter injury were at particular risk for posthysterectomy fecal incontinence.

Risk of urinary incontinence after childbirth: a 10-year prospective cohort study.

OBJECTIVE: To estimate prospectively the effect of first delivery on subjective bladder function and to assess the influence of subsequent deliveries and obstetric events METHODS: We performed a prospective, observational cohort study. During a 10-week period in 1995, 304 of 309 eligible primiparous women (98%) entered the study at the postpartum maternity ward and completed a bladder function questionnaire. The 10-year observational period was completed by 246 of 304 subjects (81%). RESULTS: Prevalence of moderate-severe stress urinary incontinence increased from 5 of 304 subjects (2%) at baseline to 27 of 229 (12%) at 10 years follow-up (P < .001). Prevalence of moderate-severe urinary urgency increased from 0 subjects (0%) at baseline to 31 of 229 (13%) at the 10-year follow-up (P < .001). The relative risk (RR) (adjusted for maternal age and parity) of moderate to severe urinary incontinence increased significantly 10 years after first delivery (RR 5.8, 95% confidence interval [CI] 1.2-33.7). At multivariable analysis adjusted for age and parity, stress urinary incontinence symptoms at 9 months and 5 years follow-up were independently associated with the presence of symptoms at 10 years after index delivery (RR 13.3, 95% CI 3.9-33.1 and RR 14.1, 95% CI 2.5-18.8, respectively). Number of vaginal deliveries or other obstetric covariates did not affect the risk of stress urinary incontinence or urinary urgency. CONCLUSION: Vaginal delivery is independently associated with a significant long-term increase in stress urinary incontinence symptoms, as well as urinary urgency, regardless of maternal age or number of deliveries. LEVEL OF EVIDENCE: II-2.

Long-term outcome of abdominal sacrocolpopexy using xenograft compared with synthetic mesh.

OBJECTIVES: To assess the clinical outcome after abdominal sacrocolpopexy using a porcine dermal graft compared with a synthetic mesh. METHODS: Patients with vaginal vault prolapse Stage II or worse (Baden-Walker staging), underwent sacrocolpopexy using a synthetic mesh (n = 25) or porcine collagen graft (n = 27). The subjective outcome was measured using validated questionnaires. RESULTS: The mean clinical follow-up from surgery was 7.1 months for the xenograft compared with 7.4 months for the synthetic cohort. At clinical follow-up, vaginal vault prolapse Stage II was present in 8 (29%) of 27 patients in the xenograft cohort and 6 (24%) of 25 patients in the synthetic mesh cohort (no significant difference). The mean follow-up from surgery to survey was 2.5 years in the xenograft cohort and 4.3 years in the synthetic cohort. None of the patients in either cohort had undergone a secondary sacrocolpopexy. No significant differences were found between the cohorts regarding surgical morbidity other than more patients experiencing fever for 1 to 3 days in the xenograft cohort (P < 0.001). No significant differences were found in lower urinary tract symptoms, anorectal symptoms, or quality-of-life variables between the two cohorts. CONCLUSIONS: Abdominal sacrocolpopexy using a porcine dermal graft was comparable to synthetic mesh in terms of subjective and anatomic outcomes at mid to long-term follow-up.

A three-year prospective assessment of rectocele repair using porcine xenograft.

OBJECTIVE: To prospectively evaluate clinical outcome of rectocele repair using xenograft 3 years after surgery. METHODS: Twenty-three patients who completed evaluation preoperatively and 1 year after surgery were assessed at a 3-year follow-up. Clinical examination was performed preoperatively, and at the 1- and 3-year follow-ups, with the pelvic organ prolapse quantification system. Symptom assessment was performed with a validated bowel function questionnaire including questions on sexual function. RESULTS: There were no graft-related complications during the 3 years following surgery. Preoperatively, all patients had stage II prolapse of the posterior vaginal wall and a rectocele verified at defecography. At the 1-year follow-up, 11 of 29 patients (38%) had rectocele of stage II or more, and 4 patients were reoperated. At 3-year follow-up 7 of 23 patients (30%) had rectocele of stage II or more. When including the 4 early anatomical recurrences, a total of 11 of 27 patients (41%) had rectocele of stage II or more at 3-year follow-up. Preoperatively, all patients reported varying degrees of rectal emptying difficulties and symptoms of bowel dysfunction. There was a significant decrease in rectal emptying difficulties (P < .01), sense of incomplete evacuation (P < .01), need for manually assisted defecation (P < .05), and symptoms of pelvic heaviness (P < .001) at the 3-year follow-up compared with preoperatively. Cure of rectal emptying difficulties was reported by fewer than 50% of patients. There were no significant changes in anal incontinence scores or symptoms of sexual dysfunction at the 3-year follow-up compared with preoperatively. CONCLUSION: Rectocele repair using porcine dermal graft was associated with an unsatisfactory anatomical cure rate and persistent bowel-emptying difficulties in the majority of patients 3 years postoperatively. LEVEL OF EVIDENCE: II-3.

Rectocele repair using biomaterial augmentation: current documentation and clinical experience.

UNLABELLED: Although the etiology of rectocele remains debated, surgical innovations are currently promoted to improve anatomic outcome while avoiding dyspareunia and alleviating rectal emptying difficulties following rectocele surgery. Use of biomaterials in rectocele repair has become widespread in a short time, but the clinical documentation of their effectiveness and complications is limited. Medline and the Cochrane database were searched electronically from 1964 to May 2005 using the Pubmed and Ovid search engines. All English language publications including any of the search terms "rectocele," "implant," "mesh," "biomaterial," "prolapse," "synthetical," "pelvic floor," "biological," and "compatibility" were reviewed. This review outlines the basic principles for use of biomaterials in pelvic reconstructive surgery and provides a condensation of peer-reviewed articles describing clinical use of biomaterials in rectocele surgery. Historical and new concepts in rectocele surgery are discussed. Factors of importance for human in vivo biomaterial compatibility are presented together with current knowledge from clinical studies. Potential risks and problems associated with the use of biomaterials in rectocele and pelvic reconstructive surgery in general are described. Although use of biomaterials in rectocele and other pelvic organ prolapse surgery offers exciting possibilities, it raises treatment costs and may be associated with unknown and potentially severe complications at short and long term. Clinical benefits are currently unknown and need to be proven in clinical studies. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians TARGET AUDIENCE: After completion of this article, the reader should be able to explain that the objective of surgical treatment is to improve anatomic outcome and alleviate rectal emptying difficulties, describe the efficacy of biomaterials in rectocele repair, and summarize the potential risks and problems associated with use of biomaterials in rectocele and pelvic reconstructive surgery.

Functional and anatomic outcome after transvaginal rectocele repair using collagen mesh: a prospective study.

PURPOSE: This study was designed to evaluate rectocele repair using collagen mesh. METHODS: 32 female patients underwent surgical repair using collagen mesh. Outcome was assessed in 29 patients and preoperative assessment included standardized questionnaire, clinical examination, and defecography. At the six-month follow-up, patients answered a standardized questionnaire and underwent clinical examination. At the 12-month follow-up, patients answered a standardized questionnaire, underwent clinical examination, and defecography. RESULTS: Preoperatively, 26 patients had a Stage II and 3 patients had a Stage III rectocele. At the 6-month follow-up, five patients had rectocele > or = Stage II (P < 0.001) and at the 12-month follow-up, seven patients had rectocele > or = Stage II (P < 0.001) at clinical examination. At the preoperative defecography, all patients presented a rectocele. At the 12-month defecography, 14 patients had no rectocele (P < 0.001) and 15 had a rectocele. At the six-month follow-up, there was a significant decrease in rectal emptying difficulties, need of digital support of the posterior vaginal wall at defecation, and defecation frequency. At the 12-month follow-up, symptom improvement remained, but was less pronounced. CONCLUSIONS: Rectocele repair using collagen mesh improved anatomic support, but there is a substantial risk for recurrence with unsatisfactory anatomic and functional outcome one year after surgery. Rectocele repair using mesh was not associated with an increased risk of dyspareunia. Rectocele repair using biomaterial mesh reinforcement needs further evaluation before adopted into clinical practice.

Anatomical outcome and quality of life following posterior vaginal wall prolapse repair using collagen xenograft.

The aim of this study was to evaluate quality of life, sexual function, and anatomical outcome after posterior vaginal wall prolapse repair using a collagen xenograft. Thirty-three patients were evaluated preoperatively and at 6 and 12 months follow-up (FU). Quality of life and sexual function were assessed using a self-reported questionnaire. Prolapse staging was performed using the pelvic organ prolapse quantification system (POPQ). Preoperatively 3 patients had stage I, 26 patients stage II, and 4 patients stage III prolapse of the posterior vaginal wall. Prolapse of the posterior vaginal wall > or = stage II was observed in 7 patients (21%) at the 6-month FU and in 13 patients (39%) at the 12-month FU. Mean point Bp was reduced from -1.1 preoperatively to -2.5 at 6 months FU (p < 0.01) and -1.8 at 12 months FU (p < 0.01). Previous abdominal surgery was associated with a less favorable anatomical outcome (odds ratio: 2.0, 95% confidence interval: 1.5-3.8). There were no significant changes in sexual function or dyspareunia during the 1-year FU. Preoperatively 76% of the patients reported a negative impact on quality of life as a result of genital prolapse. There was a significant improvement in several variables associated with quality of life at 6 and 12 months FU. Posterior vaginal wall prolapse repair using a collagen xenograft was associated with an unsatisfying anatomical outcome at 1-year FU although several quality of life-associated variables affecting psychosocial function were improved. Improvement was not restricted to postoperative restoration of vaginal topography, and previous surgery had a negative effect on anatomical outcome.

Assessment of posterior vaginal wall prolapse: comparison of physical findings to cystodefecoperitoneography.

The aim of the present study was to compare clinical and radiological findings when assessing posterior vaginal wall prolapse. Defecography can be used to complement the clinical evaluation in patients with posterior vaginal wall prolapse. Further development of the defecography technique, using contrast medium in the urinary bladder and intraperitoneally, have resulted in cystodefecoperitoneography (CDP). Thirty-eight women underwent clinical examination using the pelvic organ prolapse quantification system (POP-Q) followed by CDP. All patients answered a standardized bowel function questionnaire. Statistical analysis measuring correlation between POP-Q and CDP using Pearson's correlation coefficient (r) and Spearman's rank order correlation coefficient (rs) demonstrated a poor to moderate correlation, r=0.49 and rs=0.55. Although there was a strong association between large rectoceles (>3 cm) at CDP and symptoms of rectal emptying difficulties (p<0.001), severity and prevalence of bowel dysfunction showed poor coherence with clinical prolapse staging and findings at radiological imaging. Vaginal topography and POP-Q staging predict neither radiological size nor visceral involvement in posterior vaginal wall prolapse. Radiological evaluation may therefore be a useful complement in selected patients.

Anal incontinence after vaginal delivery: a five-year prospective cohort study.

OBJECTIVE: The long-term prevalence of anal incontinence after vaginal delivery is unknown. The aim of the present study was to evaluate the prevalence of anal incontinence in primiparous women 5 years after their first delivery and to evaluate the influence of subsequent childbirth. METHODS: A total of 349 nulliparous women were prospectively followed up with questionnaires before pregnancy, at 5 and 9 months, and 5 years after delivery. A total of 242 women completed all questionnaires. Women with sphincter tear at their first delivery were compared with women without such injury. Risk factors for development of anal incontinence were also analyzed. RESULTS: Anal incontinence increased significantly during the study period. Among women with sphincter tears, 44% reported anal incontinence at 9 months and 53% at 5 years (P = .002). Twenty-five percent of women without a sphincter tear reported anal incontinence at 9 months and 32% had symptoms at 5 years (P < .001). Risk factors for anal incontinence at 5 years were age (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0-1.2), sphincter tear (OR 2.3; 95% CI 1.1-5.0), and subsequent childbirth (OR 2.4; 95% CI 1.1-5.6). As a predictor of anal incontinence at 5 years after the first delivery, anal incontinence at both 5 months (OR 3.8; 95% CI 2.0-7.3) and 9 months (OR 4.3; 95% CI 2.2-8.2) was identified. Among women with symptoms, the majority had infrequent incontinence to flatus, whereas fecal incontinence was rare. CONCLUSION: Anal incontinence among primiparous women increases over time and is affected by further childbirth. Anal incontinence at 9 months postpartum is an important predictor of persisting symptoms.

Clinical and histological safety assessment of rectocele repair using collagen mesh.

AIM: To clinically and histologically evaluate inflammatory response following rectocele repair using porcine collagen mesh. METHODS: Seventeen patients underwent rectocele repair using porcine collagen mesh. Inflammatory response was assessed by clinical and histological inflammatory grading pre- and postoperatively. Postoperative body temperature, complications and hospital stay was compared with 15 patients undergoing posterior colporraphy. RESULTS: Postoperative clinical examination did not demonstrate any inflammatory reaction. There were no significant changes in fibroblast count (P = 0.43), connective tissue density grading (P = 0.54), macrophage count (P = 0.20), inflammatory cell count (P = 0.48), total cell count (P = 0.51), or inflammatory grading (P = 0.87) postoperatively compared with preoperative values. Body temperature was significantly elevated for both the study and control group, although higher for the study group, postoperatively day 1 (P < 0.001). There were no significant differences in hospital stay and postoperative complications. CONCLUSION: Porcine collagen mesh was not associated with an adverse inflammatory response at clinical or histological evaluation and appears to be a safe material when used for rectocele repair.

Effect of hysterectomy on bowel function.

PURPOSE: Hysterectomy is the most common major gynecologic procedure. Unwanted postoperative effects on bowel function are a topic of recent debate. The aim of the present study was to prospectively evaluate the influence of hysterectomy on bowel function. METHODS: One hundred and twenty consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire covering bowel habits and symptoms preoperatively and at 6 and 12 months postoperatively. Forty-four patients underwent vaginal hysterectomy and 76 underwent abdominal hysterectomy. Concomitant bilateral salpingo-oopherectomy was performed in 17 patients. RESULTS: After abdominal hysterectomy, patients reported increased symptoms of gas incontinence, urge to defecate, and inability to distinguish between gas and feces ( P < 0.05). There was a tendency of increased fecal incontinence. Subgroup analysis indicated that concomitant bilateral salpingo-oopherectomy resulted in an increased risk of fecal incontinence. No significant changes were detected in symptoms associated with constipation. Mean defecation frequency increased and the frequency of pelvic heaviness symptoms was reduced. After vaginal hysterectomy, there was no increased frequency of incontinence or constipation symptoms. The frequency of pelvic heaviness symptoms was reduced. CONCLUSIONS: Patients undergoing abdominal hysterectomy may run an increased risk for developing mild to moderate anal incontinence postoperatively and this risk is increased by simultaneous bilateral salpingo-oopherectomy. An increased risk of anal incontience symptoms could not be identified in patients undergoing vaginal hysterectomy. Our study does not support the assumption that hysterectomy is associated with de novo or deteriorating constipation.

Diagnosis of cystocele--the correlation between clinical and radiological evaluation.

In patients with genital prolapse involving several compartments simultaneously, radiologic investigation can be used to complement the clinical assessment. Contrast medium in the urinary bladder enables visualization of the bladder base at cystodefecoperitoneography (CDP). The aim of the present study was to evaluate the correlation between clinical examination using the Pelvic Organ Prolapse Quantification system (POP-Q) and CDP. Thirty-three women underwent clinical assessment and CDP. Statistical analysis using Pearson's correlation coefficient ( r) demonstrated a wide variability between the current definition of cystocele at CDP and POP-Q ( r=0.67). An attempt to provide an alternative definition of cystocele at CDP had a similar outcome ( r=0.63). The present study demonstrates a moderate correlation between clinical and radiologic findings in patients with anterior vaginal wall prolapse. It does not support the use of bladder contrast at radiologic investigation in the routine preoperative assessment of patients with genital prolapse.