Evaluation of levator ani muscle elasticity after vaginal delivery and cesarean section using shear wave elastography.

PURPOSE: The risk of pelvic floor muscle injury is commonly considered to be higher in vaginal than in cesarean delivery. This study aimed to compare levator ani muscle (LAM) elasticity after vaginal and cesarean delivery using shear wave elastography (SWE). METHODS: Postpartum women who underwent a single SWE evaluation 1 month after their first delivery were divided into vaginal and cesarean delivery groups. The elastic moduli of both sides of the LAM were measured in a horizontal section and compared between the groups. In addition, a subgroup analysis was performed to compare LAM elasticity according to the delivery method within the vaginal delivery group-normal vaginal delivery, episiotomy, and operative vaginal delivery. RESULTS: Sixty-two women were included (vaginal delivery, n = 47; elective cesarean section, n = 15). Multiple regression analysis revealed that the LAM elastic modulus was significantly lower in the vaginal delivery group than in the cesarean delivery group (right LAM: 44.2 vs. 72.7 kPa, p = 0.0036; left LAM 40.4 vs. 82.7 kPa, p < 0.0001). In the subgroup analysis, the right LAM elastic modulus was significantly lower in the operative vaginal delivery subgroup than in the normal vaginal delivery subgroup (p = 0.0131). However, there was no significant difference in the left LAM elastic modulus between the three subgroups. CONCLUSION: LAM elasticity was significantly lower after vaginal delivery than after cesarean delivery. Furthermore, the elasticity of the right LAM was lower after operative vaginal delivery than after normal vaginal delivery. SWE has the potential to provide an objective quantitative assessment of postpartum pelvic floor muscle recovery.

Transvaginal vesicovaginal fistula closure: A retrospective study of 28 cases at a single facility in Japan.

OBJECTIVES: We aimed to report the background of patients with vesicovaginal fistulas (VVFs) at our center, which has treated a relatively large number of such patients in Japan, as well as the ingenuity and outcomes of vesicovaginal fistula closure (VVFC). We also investigated the causes of VVFs. METHODS: A retrospective review was performed for 28 patients with VVFs treated at our center. Age, body mass index, etiology, site of fistula, and postoperative outcomes were investigated. RESULTS: Twenty-one (75%) fistulas occurred following hysterectomy. The overall success rate of VVFC was 85.7%, and the success rate limited to the first attempt was 89.5%. In 68% of cases, no bladder injury suspected as the cause of VVF was noticed during the surgery. Energy devices were used in all 12 patients for whom information on the type of device used for hysterectomy was confirmed. CONCLUSIONS: To our knowledge, this is the first report to evaluate a relatively large number of VVFCs in Japan. Although VVF is thought to be caused by bladder injury during hysterectomy, delayed thermal damage might also result in this pathology, even if there is no apparent intraoperative bladder injury.

Magnetic resonance imaging evaluation of the effectiveness of FemiCushion in pelvic organ prolapse.

AIMS: FemiCushion (FC) is a supportive device for pelvic organ prolapse (POP), but its effectiveness has not been evaluated with imaging studies. This study utilized magnetic resonance imaging (MRI) to evaluate the anatomic changes induced by FC use in patients with severe POP. METHODS: This prospective study examined patients with stage 3 or 4 POP who underwent treatment with FC and received a diagnostic MRI. Measurements were made in the midsagittal plane at rest and during straining with and without FC. The vertical distances from the lowest points of the anterior and posterior vaginal wall (A; P), uterine cervix or vaginal stump (C), and perineal body (PB) to the Pelvic Inclination Correction System line were measured, along with the lengths of the urogenital (UGH) and levator hiatus (LH). RESULTS: Twelve patients were included in the study. The median age was 72 (range, 56-84) years. All reference points were positioned significantly higher with the FC than without the FC (median ΔA: 11 mm, p = 0.005; ΔC: 14 mm, p = 0.011; ΔP: 6 mm, p = 0.008; ΔPB: 7 mm, p = 0.002). Median UGH and LH lengths during straining were significantly shorter with the FC than without the FC (UGH: 44 mm vs. 53 mm, p = 0.002; LH: 60 vs. 65 mm, p = 0.021). CONCLUSIONS: This is the first report on the use of MRI to measure the performance of FC. Our study demonstrates that FC effectively repositioned the organs involved in POP.

Evaluation of the effect of levator ani muscle contraction on post-prostatectomy urinary incontinence using cine MRI.

AIM: Post-prostatectomy urinary incontinence (PPI) is the greatest concern for urologists after radical prostatectomy (RP). It is thought that PPI is composed of multiple factors including static and dynamic components. The purpose of this study is to show visually levator ani muscle (LAM) contraction during pelvic floor muscle contraction and to evaluate the dynamic differences in its contraction between men with and without PPI. METHODS: This study was a case-control study of the urinary continent or incontinent men. It investigated whether LAM contraction was involved in urinary leakage based on examination of LAM contraction by cine magnetic resonance imaging. RESULTS: The LAM contracted from the coccyx to the pubis in the same manner before and after surgery. The degree of contraction of the LAM in post-prostatectomy groups was smaller than that in the healthy adult group. The contraction distances of each part of the pelvic floor were decreased by 50%-70% in the incontinence group compared to those in the continence group. The bladder neck moved 2.5-fold further in the continence group and the direction of movement was more vertical than in the incontinence group. Urethral compression was attenuated by about 40% in the incontinence group compared to that in the continence group. CONCLUSIONS: RP can cause damage to the LAM. LAM contraction is reduced after RP compared with that in healthy adult men. In men with PPI, the reduced muscle contraction might not compress the urethra sufficiently when abdominal pressure is raised. Pelvic floor muscle training might provide a meaningful method for the recovery of LAM contraction in patients with PPI.

Association between overactive bladder and pelvic organ mobility as evaluated by dynamic magnetic resonance imaging.

Overactive bladder (OAB) is a prevalent condition, which negatively impacts patients' quality of life. Pelvic organ prolapse (POP), also prevalent in women, has been recognized as an important etiology of female OAB, although the pathophysiological mechanisms remain controversial. In this study, we reviewed findings of dynamic magnetic resonance imaging (dMRI) in 118 patients with POP and investigated the association between dMRI findings, including positions and mobilities of pelvic organs as well as parameters of pelvic organ support and bladder outlet obstruction (urethral kinking), and OAB in order to elucidate the pathophysiology of OAB in patients with POP. Our results showed that compared with non-OAB patients, OAB patients had a significantly higher body mass index, more severe pelvic floor muscle impairment, and more profound supportive defects in the uterine cervix (apical compartment). On the other hand, dMRI parameters showed hardly any significant difference between patients with mild and moderate to severe OAB. These findings may imply that levator ani impairment and defective supports of the apical compartment could be associated with the presence of OAB and that the severity of OAB could be affected by factors other than those related to pelvic organ mobility and support or urethral kinking.

A new method of adjusting mesh tension using cystoscopy during laparoscopic sacrocolpopexy.

We aimed to examine the usefulness of cystoscopic findings to guide mesh tension adjustment during laparoscopic sacrocolpopexy (LSC) to promote better repair of pelvic organ prolapse (POP) and prevent de novo stress urinary incontinence (SUI). In this technique, the bladder wall was observed using a cystoscope when various traction pressures were applied by pulling the mesh arm with forceps before fixation to the promontory during LSC. Adjustment was performed on 20 patients, and postoperative outcomes of POP repair and development of de novo SUI were evaluated. When excessive traction was applied on the mesh arm, a bladder neck opening and a cord-like elevation in the center of the trigone and posterior wall were observed in all cases. The tension was gradually loosened, and precisely when the above-mentioned cystoscopic finding ("Central Road") disappeared, an anatomically appropriate elevation of the vaginal apex was achieved; the mesh arm was fixed to the promontory. At 6 months after LSC, anterior wall recurrences were diagnosed in four patients (beyond the hymen in one) with few symptoms, while no occurrence of de novo SUI. Cystoscopic findings during mesh tension adjustment in LSC could be useful in achieving improved POP repair.

Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition).

The present article is an abridged English translation of the Japanese Clinical Guidelines for Female Lower Urinary Tract Symptoms (second edition), published in September 2019. These guidelines consist of a total of 212 pages and are unique worldwide in that they cover female lower urinary tract symptoms other than urinary incontinence. They contain two algorithms for "primary treatment" and "specialized treatment," respectively. These guidelines, consisting of six chapters, address a total of 26 clinical questions including: (i) treatment algorithms; (ii) what are female lower urinary tract symptoms?; (iii) epidemiology and quality of life; (iv) pathology and illness; (v) diagnosis; and (vi) treatment. When the patient's symptoms mainly involve voiding and post-micturition symptoms, specialized treatment should be considered. In the event of voiding symptoms concurrent with storage symptoms, residual urine should be measured; if the residual urine volume is <100 mL, then diagnosis and treatment for storage symptoms is prioritized, and if the volume is ≥100 mL, then specialized treatment should be considered. When storage symptoms are the primary condition, then the patient is subject to the primary treatment algorithm. Specialized treatment for refractory overactive bladder includes botulinum toxin injection and sacral nerve stimulation. For stress urinary incontinence, surgical treatment is indicated, such as urethral slings. The two causes of voiding symptoms and post-micturition symptoms are lower urinary tract obstruction and detrusor underactivity (underactive bladder). Mechanical lower urinary tract obstruction, such as pelvic organ prolapse, is expected to improve with surgery.

"Central Road" cystoscopic finding: The road to worsened incontinence following laparoscopic sacrocolpopexy.

INTRODUCTION: This paper presents the "Central Road" cystoscopic finding accompanied by magnified mixed urinary incontinence following laparoscopic sacrocolopopexy. CASE PRESENTATION: A 70-year-old female experienced severe mixed urinary incontinence upon completing laparoscopic sacrocolopopexy. The cystoscopy showed a cord-like appearance in the center of the bladder trigon and posterior wall. Videourodynamics confirmed stress urinary incontinence, and chain cystourethrography indicated that the proximal urethra was open and the posterior vesicourethral angle was atypically widened. After implanting a midurethral sling, mixed urinary incontinence was cured subjectively and objectively without medication. CONCLUSION: The "Central Road" cystoscopic finding can be a signpost pointing to laparoscopic sacrocolopopexy mesh overtensioning, which can cause dekinking of the bladder neck, exacerbate stress urinary incontinence, and possibly lead to stress-induced instability. A midurethral sling successfully relieved mixed urinary incontinence in this case, but it might be necessary to loosen the laparoscopic sacrocolopopexy mesh in some other cases.

Anterior enterocele immediately after cystectomy: A case report.

An enterocele is a peritoneal herniation through or into the vagina, typically as a posterior enterocele, which develops in the rectovaginal space (pouch of Douglas or cul-de-sac). An anterior enterocele in the vesicovaginal space is a rare condition, but a possible complication after cystectomy or hysterectomy. Herein, we report a rare case of anterior enterocele after cystectomy, which required semi-urgent intervention. The patient was a 78-year-old woman (gravida 2, para 2) who underwent laparoscopic radical cystectomy for bladder carcinoma 3 months earlier. Vaginal examination showed a large stage-3 anterior enterocele without the covering vaginal wall. A transvaginal surgery was performed to repair the vagina. Mesh and Martius flaps were needed to repair the vaginal defect. In conclusion, an anterior enterocele must be suspected when pelvic organ prolapse occurs after cystectomy, and surgical repair should be performed as soon as possible because an enterocele that lacks vaginal wall covering is at high risk of rupture.

An evaluation of the impact of post-hysterectomy vesicovaginal fistula repair on the mental health of patients in a developed country.

INTRODUCTION AND HYPOTHESIS: Obstetric vesicovaginal fistulae (VVFs) occur frequently as a result of childbirth in developing countries, but occurrence of VVFs in developed countries is rare and is generally observed after hysterectomy. Moreover, there are no reports regarding the effect of post-hysterectomy VVF repair on the patients' mental health in developed countries. Our study aimed to confirm the effect of post-hysterectomy VVF repair on Japanese iatrogenic VVF patients' mental health. METHODS: A retrospective chart review was performed for 31 patients who underwent post-hysterectomy VVF repair. Each patient's urinary incontinence and mental state were evaluated using two questionnaires, the International Consultation on Incontinence Questionnaire-Short Form and the Hospital Anxiety and Depression Scale questionnaires, respectively, at baseline and at 3 or 6 months post-surgery. The Wilcoxon signed-rank test was used to compare the pre- and post-repair scores of each questionnaire, while McNemar's test was used to compare the pre- and post-repair proportions of patients with anxiety and depression. RESULTS: Of the 31 patients, 13 (41.9%) underwent hysterectomy because of malignancies. All questionnaire scores showed significant improvement after VVF repair. The prevalence of clinical anxiety and depression decreased from 51.6% to 16.1% (P < 0.01) and from 51.6% to 12.9% (P < 0.01), respectively, after VVF repair, and urine leakage through fistulae was not observed in any patient after VVF repair. CONCLUSIONS: Our results suggest that iatrogenic VVF can have severe impacts on patients' mental health, but VVF repair can significantly improve it.

Influence of adequate pelvic floor muscle contraction on the movement of the coccyx during pelvic floor muscle training.

[Purpose] Pelvic floor muscle training is a first-line therapy for female stress urinary incontinence. Previous studies have suggested that the coccyx tip moves ventrally and cranially during pelvic floor muscle contraction. The study aimed to elucidate the influence of adequate pelvic floor muscle contraction on coccyx movement. [Subjects and Methods] Sixty-three females (57 patients with stress urinary incontinence and additional 6 healthy volunteers) were enrolled. Using magnetic resonance imaging, coccyx movement was evaluated during pelvic floor muscle contraction and strain. An adequate contraction was defined as a contraction with good Oxford grading scale [≥3] and without inadequate muscle substitution patterns. [Results] Inadequate muscle substitution patterns were observed in 33 participants (52.4%). No significant difference was observed in the movement of the coccyx tip in the ventrodorsal direction between females with and without inadequate muscle substitution patterns. However, a significant increase in the movement of the coccyx tip in the cranial direction was detected in the group without inadequate muscle substitution patterns. Compared to participants with inadequate pelvic floor muscle contraction, those who had adequate pelvic floor muscle contraction exhibited significantly increased cranial movement of the coccyx. [Conclusion] Adequate pelvic floor muscle contraction can produce cranial movement of the coccyx tip.

Sexual activity and quality of life in Japanese pelvic organ prolapse patients after transvaginal mesh surgery.

AIM: This study aimed to evaluate sexual activity and quality of life (QOL) after transvaginal mesh (TVM) surgery in Japanese patients with pelvic organ prolapse (POP). The objective cure rate and associated complications were also investigated. METHODS: The cases of patients who underwent TVM surgery were retrospectively analyzed. QOL was assessed using the Prolapse Quality of Life Questionnaire (P-QOL), and sexual function was evaluated using the Female Sexual Function Index (FSFI) before surgery and 12 months after surgery. RESULTS: A total of 237 patients completed the planned follow-up examinations. All P-QOL domains were significantly improved after surgery. In total, 6 (2.5%), 5 (2.1%), 13 (5.5%), 4 (1.7%) and 1 (0.4%) patients developed recurrent POP, mesh extrusion, de novo stress urinary incontinence, inguinal pain and de novo dyspareunia, respectively. Before surgery, 124 of the 237 patients (52.3%) refused to complete the FSFI because they had not engaged in any sexual activity. Among the 113 patients who completed the FSFI, 13 (11.5%) were sexually active. After surgery, 79 patients completed the FSFI, and 14 (17.7%) were sexually active. The overall scores for sexual function and arousal were significantly improved after surgery. CONCLUSION: Patients who underwent TVM surgery at our institution exhibited quite low sexual activity levels both before and after the operation. But TVM surgery achieved good QOL outcomes, a high success rate and a low complications rate at 12 months in Japanese POP patients. TVM implantation for POP is safe and effective in sexually inactive patients.

Short-term outcomes of the transvaginal minimal mesh procedure for pelvic organ prolapse.

Purpose: This study aimed to evaluate the clinical outcomes and complications of transvaginal minimal mesh repair without using commercially available kits for treatment of pelvic organ prolapse (POP). Materials and Methods: This retrospective cohort study involved 91 women who underwent surgical management of POP with originally designed small mesh between July 2014 and August 2015. This mesh is 56% smaller than the mesh widely used in Japan, and it has only two arms delivered into each right and left sacrospinous ligament. The main study outcome was the anatomic cure rate defined as recurrence of POP quantification (POP-Q) stage II or more. We also assessed changes in the overactive bladder symptom score (OABSS) and prolapse quality of life questionnaire (P-QOL) and evaluated adverse events. Finally, we compared patient backgrounds between the patients with and without recurrence. Results: Prolapse recurred in 10 of 91 patients (11.0%), and all patients with recurrence were diagnosed as POP-Q stage II. As adverse events, only mesh erosion occurred in two (2.2%) and pelvic pain in one (1.1%) of the 91 patients. The OABSS and P-QOL were significantly improved by the operation. When we compared patient backgrounds between the patients with and without recurrence, body mass index was the only factor influencing affecting recurrence. Conclusions: Transvaginal minimal mesh repair resulted in successful outcomes with low mesh-related complications and anatomic recurrence at one year. Furthermore, significant improvement in QOL was offered by this procedure. Our minimal mesh technique should be considered as one treatment option for the management of POP.

Long-term Persistence with Mirabegron versus Solifenacin in Women with Overactive Bladder: Prospective, Randomized Trial.

OBJECTIVES: To compare persistence with medication and the reasons for discontinuation of mirabegron or solifenacin therapy up to12 months in women with overactive bladder (OAB). METHODS: Female OAB patients who presented to women's urology clinics were enrolled in a prospective, randomized, two-arm study. Patients were randomized to receive mirabegron at 25-50 mg (n = 76) or solifenacin at 2.5-5 mg (n = 72). The persistence rate and the reasons for discontinuation were investigated up to 12 months. RESULTS: The 12-month persistence rate was 12.2% in the mirabegron group versus 20.1% in the solifenacin group and there were no significant differences of the persistence rates during the study (n.s). Patients discontinued treatment because of lack of efficacy (21.6%), spontaneous improvement (18.2%), and side-effects (17.6%), while 19.6% were lost to follow up. Discontinuation due to side-effects was significantly more frequent in the solifenacin group than the mirabegron group (27.3 vs. 7.9%, P < 0.05). In contrast, discontinuation due to lack of efficacy was significantly more frequent in the mirabegron group than the solifenacin group (36.8 vs. 5.6%, P < 0.05). CONCLUSIONS: This study demonstrated low persistence rates over 12 months for both mirabegron and solifenacin, although the reasons for discontinuation were somewhat different.

Clinical Guideline for Female Lower Urinary Tract Symptoms.

The "Japanese Clinical Guideline for Female Lower Urinary Tract Symptoms," published in Japan in November 2013, contains two algorithms (a primary and a specialized treatment algorithm) that are novel worldwide as they cover female lower urinary tract symptoms other than urinary incontinence. For primary treatment, necessary types of evaluation include querying the patient regarding symptoms and medical history, examining physical findings, and performing urinalysis. The types of evaluations that should be performed for select cases include evaluation with symptom/quality of life (QOL) questionnaires, urination records, residual urine measurement, urine cytology, urine culture, serum creatinine measurement, and ultrasonography. If the main symptoms are voiding/post-voiding, specialized treatment should be considered because multiple conditions may be involved. When storage difficulties are the main symptoms, the patient should be assessed using the primary algorithm. When conditions such as overactive bladder or stress incontinence are diagnosed and treatment is administered, but sufficient improvement is not achieved, the specialized algorithm should be considered. In case of specialized treatment, physiological re-evaluation, urinary tract/pelvic imaging evaluation, and urodynamic testing are conducted for conditions such as refractory overactive bladder and stress incontinence. There are two causes of voiding/post-voiding symptoms: lower urinary tract obstruction and detrusor underactivity. Lower urinary tract obstruction caused by pelvic organ prolapse may be improved by surgery.

Core lower urinary tract symptom score (CLSS) for the assessment of female lower urinary tract symptoms: a comparative study.

OBJECTIVE: We have recently developed the core lower urinary tract symptom score (CLSS) questionnaire to readily address 10 important lower urinary tract symptoms (LUTS). The aim of the present study was to evaluate the performance of the CLSS in women compared with the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS). METHODS: Three hundred and eighteen treatment-naïve consecutive female patients, including 48 controls, completed the three questionnaires. Quality of life (QOL) was determined as per the IPSS QOL Index. The clinical diagnoses were overactive bladder (n = 69), mixed incontinence (n = 42), stress incontinence (n = 17), pelvic organ prolapse (n = 56), interstitial cystitis (n = 31), bacterial cystitis (n = 16), underactive bladder (n = 16), and "other" (n = 23). Simple statistics and the relationship between symptom scores and poor QOL (QOL Index ≥ 4) were examined. RESULTS: All symptom scores were significantly increased in symptomatic women. The CLSS described the symptom profiles of patients with distinct conditions. The scores of corresponding symptoms on the three questionnaires were significantly correlated (r = 0.51-0.85; all P < 0.0001). Multivariate logistic regression modeling proved five CLSS symptoms (daytime frequency, nocturia, urgency incontinence, straining, and urethral pain) as independent predictors of poor QOL, with hazard ratios ranging from 2.0 to 4.2. The IPSS included only two (urgency and straining) significant symptoms. CONCLUSIONS: The IPSS alone does not fully evaluate female LUTS, with a possible negative impact on QOL. Using the CLSS questionnaire would enable a simple and comprehensive assessment of female LUTS.

Surgical treatment of female stress urinary incontinence with a transobturator tape (Monarc): short-term results of a prospective multicenter study.

AIM: Transobturator tape (TOT) kits approved as medical instruments are still not available in Japan. This study aimed to: (1) assess the outcomes of TOT using Monarc (American Medical Systems; AMS Inc, Minnetonka, MN, USA) in women with stress urinary incontinence (SUI); (2) evaluate possible different surgical outcomes in women with urethral hypermobility (UH) and/or intrinsic urethral deficiency (ISD); and (3) evaluate the possibility of improvement of preoperative urgency and urge urinary incontinence after TOT in mixed urinary incontinence (MUI). METHODS: Data from 140 women with SUI in a prospective multicenter study were examined at 3-6 months follow-up. RESULTS: 82.1% of the patients were cured and 10.7% showed improvement. The surgical outcome was significantly better in UH than in UH combined with ISD or ISD. In 44 MUI patients, 79.6% were cured and 15.9% showed improvement. Urgency improved in about 75% of patients after TOT. CONCLUSION: TOT is effective for both SUI and MUI, with urgency improving.