Optimizing practices to prevent urinary tract infection after cystoscopy and urodynamics in women: A quality improvement study.

OBJECTIVE: The objective of this study was to reduce the incidence of urinary tract infection (UTI) in women undergoing outpatient cystoscopy and/or urodynamic studies (UDS) at our centre by identifying and then altering modifiable risk factors through an analysis of incidence variability among physicians. METHODS: This was a quality improvement study involving adult women undergoing outpatient cystoscopy and/or UDS at an academic tertiary urogynecology practice. Prophylactic practices for cystoscopy/UDS were surveyed and division and physician-specific UTI rates following cystoscopy/UDS were established. In consultation with key stakeholders, this delineated change concepts based on associations between prophylactic practices and UTI incidence, which were then implemented while monitoring counterbalance measures. RESULTS: Two "Plan-Do-Study-Act-Cycles" were conducted whereby 212 and 210 women were recruited, respectively. Change concepts developed and implemented were: (1) to perform routine urine cultures at the time of these outpatient procedures, and (2) to withhold routine prophylactic antibiotics for outpatient cystoscopy/UDS, except in patients with signs of cystitis. There was no change in the incidence of early presenting UTI (9.0% vs. 9.2%, p = 0.680), but there were significantly fewer antibiotic-related adverse events reported (8.5% vs. 1.5%, p = 0.001). There was no significant change in the total incidence of UTI rates between cycles (7.8% vs. 5.6%, p = 0.649). CONCLUSIONS: No specific strategies to decrease the incidence of UTI following outpatient cystoscopy/UDS were identified, however, risk factor-specific antibiotic prophylaxis, as opposed to universal antibiotic prophylaxis, did not increase UTI incidence.

The Future of Basic Science: Development of the Next Generation of Mechanistic Researchers in Female Pelvic Medicine.

INTRODUCTION AND HYPOTHESIS: The International Urogynecological Association (IUGA) brought together senior and junior members actively engaged in scholarly and educational activities for a consensus conference centered on developing a strategy for sustainable training of the next generation of mechanistic researchers in female pelvic medicine. METHODS: Four a priori identified major foci were explored in a half-day virtual consensus conference. Participants included representatives from various countries and disciplines with diverse backgrounds-clinicians, physician-scientists, and basic scientists in the fields of urogynecology, biomechanical engineering, and molecular biology. Following a keynote address, each focus area was first tackled by a dedicated breakout group, led by the Chair(s) of the most relevant IUGA committees. The break-out sessions were followed by an iterative discussion among all attendees to identify mitigating strategies to address the shortage of mechanistic researchers in the field of female pelvic medicine. RESULTS: The major focus areas included: research priorities for IUGA basic science scholar program; viable strategies for sustainable basic science mentorship; core competencies in basic science training; and the challenges of conducting complex mechanistic experiments in low-resource countries. Key gaps in knowledge and core competencies that should be incorporated into fellowship/graduate training were identified, and existing training modalities were discussed. Recommendations were made for pragmatic approaches to increasing the exposure of trainees to learning tools to enable sustainable training of the next generation of basic science researchers in female pelvic medicine worldwide. CONCLUSIONS: The attendees presented multiple perspectives to gain consensus regarding critical areas of need for training future generations of mechanistic researchers. Recommendations for a sustainable Basic Science Scholar Program were developed using IUGA as a platform. The overarching goal of such a program is to ensure a successful bench-to-bedside-and-back circuit in Urogynecology and Pelvic Reconstructive Surgery, ultimately improving lives of millions of women worldwide through scientifically rational effective preventative and therapeutic interventions.

Correlation of anorectal symptoms and endoanal ultrasound findings after obstetric anal sphincter injuries (OASIS).

INTRODUCTION: Obstetric anal sphincter injuries (OASIS) predispose to development of anorectal symptoms that affect women's quality of life. METHODS: A retrospective cohort study was conducted for all women with singleton vaginal deliveries who had a primary OASIS repair and attended the Postpartum Perineal Clinic between July 1st 2017 and December 31st 2020. This study was approved by the Research Ethics Board. The purpose of this study was (1) to determine correlation between endoanal ultrasound (EAUS) findings and anorectal symptoms quantified by the St. Mark's Incontinence Score (SMIS), (2) to determine the incidence of residual anal sphincter defects, and (3) to determine the rate of clinical overdiagnosis of OASIS. Pearson correlation coefficient was used to assess correlation between anorectal symptoms and EAUS findings. RESULTS: A total of 247 participants with clinical diagnosis of OASIS met the inclusion criteria. A 3rd-degree tear was identified in 126 (51.0%) and 4th-degree tear was identified in 30 (12.1%) participants. In participants with sonographic evidence of OASIS, there was a statistically significant weak positive correlation between the size of residual defect and SMIS for both external anal sphincter (EAS) (r = .3723, p < .0001) and internal anal sphincter (IAS) (r = .3122, p = .0180). Residual defect in the anorectal sphincter of greater than 1 hour (> 30°) in width was present in 64.3% participants with 3rd-degree tear and 86.7% participants with 4th-degree tear. The rate of overdiagnosis was 36.8%. CONCLUSION: The size of residual defect of EAS and IAS has a weak positive correlation with anorectal symptoms, emphasizing the importance of EAUS for counselling regarding mode of subsequent delivery.

The effect of local estrogen therapy on the urinary microbiome composition of postmenopausal women with and without recurrent urinary tract infections.

INTRODUCTION AND HYPOTHESIS: Recurrent urinary tract infections (rUTIs) occur in 2-10% of postmenopausal women. Local estrogen therapy (LET) has been shown to reduce UTIs. This study aimed to compare the urinary microbiome between patients with and without a history of rUTIs and to examine whether treatment with LET influences the diversity and richness of microbiome species in two groups. METHODS: Postmenopausal women with and without rUTIs attending the urogynecology clinic between April 2019 and December 2020 were recruited. Participant baseline characteristics and demographics were recorded. Aseptic transurethral urine samples were collected at recruitment and at 3-6 months following treatment with LET. The V1-V2 and ITS regions of the 16S rRNA gene were sequenced to identify bacteria. RESULTS: A total of 37 women were recruited, 20 controls and 17 patients with rUTI. During follow-up, symptomatic UTIs occurred in 3/17 (17.6%) and 0/20 in the rUTI group and control group, respectively. Klebsiella aerogenes was present in 80% of rUTI samples and in 53.3% of control samples before LET. Abundance of Finegoldia magna was present in 33.3% of samples before LET, but only in 6.7% after LET. There was no change in relative abundance of lactobacillus species following LET in both groups. CONCLUSIONS: Treatment with vaginal LET altered the local hormonal environment of the urinary bladder and likely protected women from development of rUTI by decreasing the presence of F. magna. To confirm the significance of this bacterial species in rUTI symptomatology, our finding needs to be validated on a larger patient cohort.

Long-Term Experience with Modified McCall Culdoplasty in Women Undergoing Vaginal Hysterectomy for Pelvic Organ Prolapse.

OBJECTIVE: The incidence of post-hysterectomy vault prolapse following native tissue repair has been reported to be as high as 43%. The optimal way to maintain vault support is unknown. Our aim was to evaluate the long-term efficacy of modified McCall culdoplasty during vaginal hysterectomy for symptomatic uterine prolapse in preventing the recurrence of vaginal vault prolapse. METHODS: We conducted a retrospective chart review involving 490 patients who underwent vaginal hysterectomy with modified McCall culdoplasty, with or without a concomitant stress incontinence procedure, between January 2008 and December 2018 at Mount Sinai Hospital in Toronto. Data analyzed included patient demographics, preoperative prolapse staging, intraoperative and postoperative complications, and postoperative subjective and objective success rates. RESULTS: A total of 490 patients underwent vaginal hysterectomy with modified McCall culdoplasty. The mean follow-up period was 2.8 years. The objective success rate of vault support was 97.1%, and the subjective success rate was 94.1%. The total rate of reoperation for recurrence of vault prolapse was 1.0%. The objective cystocele recurrence rate was 8.6%, and 2.4% of these cases required reoperation. The objective rectocele recurrence rate was 4.7%, with 1.2% requiring reoperation. Unilateral ureteric kinking requiring intraoperative release of the McCall suture was recorded for 2.9% of patients. Overall, there was significant improvement in urinary, bowel, and prolapse symptoms post procedure. CONCLUSION: This cohort of patients who underwent modified McCall culdoplasty had low rates of vault prolapse recurrence and prolapse symptoms. The modified McCall culdoplasty technique practised at our institution is safe and effective in preventing post-hysterectomy vault prolapse.

Residual Defects of the Anal Sphincter Complex Following Primary Repair of Obstetrical Anal Sphincter Injuries at a Large Canadian Obstetrical Centre.

OBJECTIVES: To determine the rates of residual anal sphincter defect following primary repair of obstetrical anal sphincter injury (OASIS), and to assess symptomatology in these patients. METHODS: A retrospective observational study of patients who underwent primary repair of an OASIS sustained at Mount Sinai Hospital from January 2016 to June 2017. Records were reviewed for demographic and obstetrical data, symptoms of anal incontinence (AI), and the results of endoanal ultrasonography (EA-US). RESULTS: One hundred and one women sustained an OASIS during the study period, of whom 53 had EA-US performed at Mount Sinai Hospital; 4 women were excluded from this analysis. There were 42 third-degree tears and 7 fourth-degree tears. EA-US revealed residual defects in 22 patients with third-degree tears and 5 patients with fourth-degree tears (52% vs. 71%; P = 0.44).  Twelve patients with third-degree tears and 4 patients with fourth-degree tears reported AI (29% vs. 57%; P = 0.20). EA-US revealed no evidence of a tear in 14 patients clinically diagnosed with third-degree tears and 1 patient clinically diagnosed with a fourth-degree tear (33% vs. 14%). CONCLUSION: These data demonstrate deficiencies in diagnosis and repair of OASIS. Continued training for health care providers on identification and effective repair of OASIS may improve outcomes for women who experience this complication.

Effectiveness of hormones in postmenopausal pelvic floor dysfunction-International Urogynecological Association research and development-committee opinion.

INTRODUCTION AND HYPOTHESIS: There is clear evidence of the presence of estradiol receptors (ERs) in the female lower urinary and genital tract. Furthermore, it is a fact that estrogen deficiency after menopause may cause atrophic changes of the urogenital tract as well as various urinary symptoms. Moreover, the effect of hormone replacement therapy (HRT) on urinary incontinence (UI) symptoms as well as pelvic organ prolapse (POP), anal incontinence (AI) and vulvovaginal symptoms (VVS) is still a matter of debate. This committee opinion paper summarizes the best evidence on influence of sex steroids as well as hormonal treatment (local and systemic) in postmenopausal women with pelvic floor disorders. METHODS: A working subcommittee from the International Urogynecology Association (IUGA) Research and Development Committee was formed. A thorough literature search was conducted and an opinion statement expressed. The literature regarding hormones and pelvic floor disorders was reviewed independently and summarized by the individual members of the sub-committee. RESULTS: The majority of studies reported that vaginal estrogen treatment when compared with placebo has more beneficial effects on symptoms and signs of vaginal atrophy including sensation of burning, dyspareunia and UI symptoms. Definitive evidence on local estrogen application and prolapse treatment or prevention is lacking. A statistically significant increase in risk of worsening of UI as well as development of de novo incontinence was observed with estrogen-only or combination systemic HRT. CONCLUSIONS: In summary, local estrogen seems to be safe and effective in the treatment of VVS and can also improve urinary symptoms in postmenopausal patients with UI, but most of these recommendations correspond to evidence level 2C. The evidence in POP is still scarce but not in favor of benefit. Finally, the duration of local estrogen treatment (LET), optimal dosage, long-term effects and cost-effectiveness compared with current practice are still unknown.

Is overactive bladder independently associated with anxiety?

INTRODUCTION AND HYPOTHESIS: Although some psychiatric anxiety questionnaires include overactive bladder (OAB) questions, there are few controlled data to confirm such an association. We tested the association between OAB and anxiety using a control group of women with non-OAB lower urinary tract symptoms (LUTS). METHODS: Patients referred to a urogynecology clinic for LUTS completed two questionnaires: the International Consultation on Incontinence Modular Questionnaire for Overactive Bladder (ICIQ-OAB), and the Generalized Anxiety Disorder 7-Item Scale (GAD-7). Based on ICIQ-OAB scores, patients were dichotomized as having OAB versus LUTS-other, and GAD-7 scores categorized patients as having anxiety. A 2-tailed Fisher's exact test was used to test the association between OAB and anxiety. Demographic variables were collected and significant confounders were included in a logistic regression analysis. Sample size calculation indicated a need for 100 subjects, but we recruited 105 subjects to account for incomplete questionnaires. RESULTS: One hundred and five subjects were enrolled (one excluded owing to incomplete questionnaires). Sixty-five patients had OAB and 39 had LUTS-other. Of the OAB patients, 17 out of 65 (26.2%) had anxiety, compared with 3 out of 39 (7.7%) of the LUTS-other group (p = 0.038 by Fisher's exact test, with a slight drop to p = 0.056 in the regression analysis). CONCLUSIONS: There appears to be an association between OAB and anxiety and it may be of clinical importance to assess for anxiety in patients that present with OAB symptoms. The drop in statistical significance from p = 0.038 to a borderline significance of p = 0.056 in the regression analysis may be a reflection of the sample size.

Local oestrogen therapy modulates extracellular matrix and immune response in the vaginal tissue of post-menopausal women with severe pelvic organ prolapse.

This study investigates the effect of local oestrogen therapy (LET) on the expression of proteins participating in collagen/elastin biogenesis and immune markers in vaginal tissues of post-menopausal women with severe pelvic organ prolapse (POP). Vaginal biopsies were collected from the anterior vaginal wall of informed and consented 52 post-menopausal women with severe POP undergoing total hysterectomy. Twenty-nine of the 52 women were treated with LET (in the form of vaginal oestrogen cream or tablet), while the remaining 23 untreated patients served as the controls. This study was approved by Sinai Health System REB. Vaginal tissue specimens were analysed for gene and protein expression using real-time RT-PCR and Luminex assays, protein localization and immune cell infiltration were assessed by immunohistochemistry. Forty-four cytokines were detected. We found that LET application: (a) significantly increased (P < 0.05) gene and protein expression levels of extracellular matrix (ECM) structural proteins, collagen and elastin, as well as the expression of ECM maturation enzyme BMP1; (b) decreased protein expression level of ECM degradation enzymes MMP1, MMP2 and MMP3 accompanied by an increase in their tissue inhibitors, TIMP1 and TIMP4; (c) significantly increased (P < 0.05) the gene and protein expression levels of 14 vaginal cytokines involved in leucocyte infiltration, which was confirmed by immunohistochemistry. Our results indicate that LET plays an important role in the activation of immune system within the local vaginal environment, limiting the undesirable ECM degradation, which supports the strengthening of vaginal ECM in post-menopausal women, therefore resisting menopause/age-related changes and inducing urogenital tract tissue regeneration.

Does low-dose gapapentin reduce opioid use postoperatively?: A randomized controlled trial in women undergoing reconstructive pelvic surgery.

INTRODUCTION AND HYPOTHESIS: Pre-emptive gabapentin has been shown to decrease postoperative pain in abdominal and vaginal hysterectomy. However, the effect of pre-emptive low-dose gabapentin has not been studied in vaginal hysterectomy combined with concomitant pelvic reconstruction. METHODS: A randomized double-blind placebo-controlled trial assessed all women seen for symptomatic prolapse requiring vaginal hysterectomy with concomitant pelvic reconstruction with or without midurethral sling. Gabapentin dosing was 600 mg (<65 years) or 300 mg (>65 years). The primary outcome was reduction in opioid consumption in the first 24 h after surgery. Secondary outcomes included sedation and prolongation of recovery room stay. Sample-size calculations indicated a need for 22 participants/group. Student's t test was used to compare differences in oral administration of morphine equivalents in the first 24 h postoperatively, time from end of surgery to leaving the recovery room, and length of recovery room stay. Mann-Whitney U test was used to compare visual analog scale (VAS) scores for anxiety, drowsiness/sedation, pain, and nausea. RESULTS: Twenty-one patients received gabapentin and 26 a placebo capsule. Groups were similar with respect to age, menopause status, parity, American Society of Anesthesiologist (ASA) class, and concomitant procedures. There were also no significant differences between groups in opioid requirements within the first 24 h after surgery, time from end of surgery to leaving the recovery room, length of time in recovery room, or VAS scores. CONCLUSIONS: Pre-emptive gabapentin at our institutional low doses did not significantly affect postoperative pain and opioid requirements in women undergoing vaginal hysterectomy with concomitant reconstruction. TRIAL REGISTRATION: www.clinicaltrials.gov , #NCT02999724.

A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse.

OBJECTIVE: To describe a streamlined laparoscopic sacrocolpopexy (LSCP) surgical technique in women with post-hysterectomy vault prolapse and to evaluate the functional outcomes, complication rates, and surgical morbidity within our centre. METHODS: We retrospectively reviewed the charts of 180 patients scheduled for LSCP between November 2002 and May 2013 in a tertiary care centre. Patients were followed-up at six weeks, six months, and yearly after surgery. We reviewed patient demographics, preoperative and postoperative symptoms, and perioperative variables. Objective success of the surgery was defined as having a less than stage 2 vault prolapse, and subjective success was defined as the absence of bulge or prolapse symptoms. Success and complication rates were calculated. RESULTS: Of the 180 patients who underwent surgery, 144 patients underwent the procedure as planned and had at least six months of follow-up. At the last follow-up visit, 133 of these 144 patients (92.4%) were free of prolapse symptoms. Several bladder and bowel symptoms showed significant improvement. Anatomical success of vault support was achieved in 140 of 144 patients (97.2%), and 119 patients (82.6%) had no prolapse beyond the hymen. Early complications (within the first 6 weeks) occurred in 8.3% of 162 patients with limited outcome data, and late complications (after 6 weeks) occurred in 11.5% of the 144 patients with long-term data. There were no cystotomies or mesh exposures. CONCLUSION: At an average of 32 months, this cohort of patients had low prolapse recurrence rates and no reports of cystotomy or mesh erosion. The abridged LSCP technique, as practised in our institution, is safe and effective in the surgical management of post-hysterectomy vault prolapse.

Static Mechanical Loading Influences the Expression of Extracellular Matrix and Cell Adhesion Proteins in Vaginal Cells Derived From Premenopausal Women With Severe Pelvic Organ Prolapse.

INTRODUCTION: Primary human vaginal cells derived from women with severe pelvic organ prolapse (POP-HVCs) demonstrate altered cellular characteristics as compared to cells derived from asymptomatic women (control-HVCs). Using computer-controllable Flexcell stretch unit, we examined whether POP-HVCs react differently to mechanical loading as compared to control-HVCs by the expression of extracellular matrix (ECM) components, cell-ECM adhesion proteins, and ECM degrading and maturating enzymes. METHODS: Vaginal tissue biopsies from premenopausal patients with Pelvic Organ Prolapse Quantification System stage ≥3 (n = 8) and asymptomatic controls (n = 7) were collected during vaginal hysterectomy or repair. Human vaginal cells were isolated by enzymatic digestion, seeded on collagen (COLI)-coated plates, and stretched (24 hours, 25% elongation). Total RNA was extracted, and 84 genes were screened using Human ECM and Adhesion Molecules polymerase chain reaction array; selected genes were verified by quantitative reverse transcription-polymerase chain reaction. Stretch-conditioned media (SCM) were collected and analyzed by protein array, immunoblotting, and zymography. RESULTS: In mechanically stretched control-HVCs, transcript levels of integrins (ITGA1, ITGA4, ITGAV, and ITGB1) and matrix metalloproteinases (MMPs) 2, 8, and 13 were downregulated (P < .05); in POP-HVCs, MMP1, MMP3, and MMP10, ADAMTS8 and 13, tissue inhibitor of metalloproteinases (TIMPs) 1 to 3, ITGA2, ITGA4, ITGA6, ITGB1, contactin (CNTN1), catenins (A1 and B1), and laminins (A3 and C1) were significantly upregulated, whereas COLs (1, 4, 5, 6, 11, and 12) and LOXL1 were downregulated. Human vaginal cells massively secrete MMPs and TIMPs proteins; MMP1, MMP8, MMP9 protein expression and MMP2 gelatinase activity were increased, whereas TIMP2 decreased in SCM from POP-HVCs compared to control-HVCs. CONCLUSIONS: Primary human vaginal cells derived from women with severe pelvic organ prolapse and control-HVCs react differentially to in vitro mechanical stretch. Risk factors that induce stretch may alter ECM composition and cell-ECM interaction in pelvic floor tissue leading to the abatement of pelvic organ support and subsequent POP development.

Comparative Characterization of Vaginal Cells Derived From Premenopausal Women With and Without Severe Pelvic Organ Prolapse.

BACKGROUND: This study tested a hypothesis that primary human vaginal cells derived from tissue of premenopausal women with severe pelvic organ prolapse (POP-HVCs) would display differential functional characteristics as compared to vaginal cells derived from asymptomatic women with normal pelvic floor support (control-HVCs). METHODS: Vaginal tissue biopsies were collected from premenopausal patients with POP (n = 8) and asymptomatic controls (n = 7) during vaginal hysterectomy or repair. Primary vaginal cells were isolated by enzymatic digestion and characterized by immunocytochemistry. Cell attachment and proliferation on different matrices (collagen I, collagen II, collagen IV, fibronectin, laminin, tenascin, and vitronectin) were compared between POP-HVCs and control-HVCs. RNA was extracted, and the expression of 84 genes was screened using Human Extracellular Matrix and Adhesion Molecules RT(2) Profiler PCR array. The expression of selected genes was verified by quantitative reverse transcription-polymerase chain reaction. RESULTS: (1) Control-HVCs attached to collagen IV more efficiently than POP-HVCs; (2) control-HVCs and POP-HVCs show a similar proliferation rate when plated on proNectin and collagen I; (3) when seeded on collagen I, resting POP-HVCs expressed significantly (P < .05) increased transcript levels of collagen VII, multiple matrix metalloproteinases (MMP3, MMP7, MMP10, MMP12, MMP13, and MMP14), integrins (ITGA1, ITGA4, ITGA6, ITGA8, ITGB1, ITGB2, and ITGB3), and cell adhesion molecules as compared to control-HVCs. Collagen XV and tissue inhibitors of MMPs (TIMP1 and TIMP2) as well as genes involved in the biogenesis and maturation of collagen and elastin fibers (LOX, LOXL1-LOXL3, BMP1, and ADAMTS2) were significantly downregulated in POP-HVCs versus control-HVCs (P < .05). CONCLUSIONS: Resting primary POP-HVCs in vitro show altered cellular characteristics as compared to control-HVCs, which may influence their dynamic responses to external mechanical or hormonal stimuli.

Attachment of Primary Vaginal Fibroblasts to Absorbable and Nonabsorbable Implant Materials Coated With Platelet-Rich Plasma: Potential Application in Pelvic Organ Prolapse Surgery.

OBJECTIVES: Pelvic organ prolapse (POP) is a common condition in women. The lifetime risk of undergoing surgery to correct POP is 11%, with 30% recurrence rate. Various types of vaginal implants, absorbable and nonabsorbable, that have been introduced in pelvic floor reconstructive surgeries have numerous serious adverse effects. Platelet-rich plasma (PRP) is an autologous product that accelerates tissue healing and regeneration. We hypothesized that autologous PRP will promote human vaginal fibroblast (HVF) attachment to vaginal implants and increase their healing potential. METHODS: Vaginal tissue biopsies were collected from postmenopausal patients with POP (n = 10) and asymptomatic control subjects (n = 4) during vaginal hysterectomy or repair. Primary cells were isolated and characterized by immunocytochemistry. Cell attachment and proliferation were compared between POP HVFs and control HVFs (n = 4/group). Twelve weeks after the surgery, blood samples were collected from 6 POP patients to obtain autologous PRP. Two meshes, absorbable (Vicryl) and nonabsorbable (Restorelle), were coated in PRP or control media; autologous POP HVFs (n = 6) were seeded on meshes for 2 hours. Cells attached to the meshes were fixed, stained with DAPI (4,6-diamidino-2-phenylindole dihydrochloride), and counted. RESULTS: Pelvic organ prolapse HVFs were similar to control HVFs in attachment to different matrix substrates and in proliferation rate. Attachment of POP HVFs to both meshes was significantly increased after coating with PRP versus Dulbecco modified Eagle medium (Vicryl: 9875 vs. 1006 cells/cm, Restorelle: 3724 vs. 649 cells/cm; P < 0.001 for both). CONCLUSIONS: In vitro, primary POP HVFs show better attachment to implant materials when treated with PRP, which may lead to reduced mesh-related complications in vivo, indicating its great potential for urogynecologic surgeries.

Prevalence of obstructive sleep apnea detected by the Berlin Questionnaire in patients with nocturia attending a urogynecology unit.

INTRODUCTION AND HYPOTHESIS: Nocturia has been associated with several chronic conditions including obstructive sleep apnea (OSA). The pathophysiological link between nocturia and OSA has been well delineated, but the prevalence of this condition in patients with nocturia is unknown. The aim of this study was to determine the prevalence of sleep apnea in patients with nocturia compared with patients without nocturia in a group of women referred to a urogynecology unit. METHODS: After ethics approval, a cross-sectional case control study including 81 cases and 79 controls was conducted. The sample size of 72 patients was required for each arm to detect a 23 % difference in the prevalence of OSA with a 95 % confident interval (CI) and statistical power of 80 %. All patients completed the Nocturia, Nocturia Enuresis and Sleep Interruption Questionnaire (NNES-Q) and the Berlin OSA Questionnaire. The NNES-Q was used to define cases and controls. The Berlin Questionnaire was used to classify patients as being at a high or a low risk of having OSA. Univariate analysis was first performed, followed by logistic regression to assess the association between nocturia and OSA, as well as other possible variables associated with nocturia. RESULTS: Fifty of the cases (61.7 %) were classified as being at a high risk of having OSA compared with only 19 (24.1 %) in the control group (OR 2.9, 95 % CI 1.29-6.52, p = 0.01). Other variables found to be statistically significant by logistic regression were high BMI, overactive bladder, and low bladder capacity (<300 cc). CONCLUSION: Patients with nocturia showed a significantly higher risk of having OSA. Patients with nocturia should be screened for OSA.

Expression of extracellular matrix-remodeling proteins is altered in vaginal tissue of premenopausal women with severe pelvic organ prolapse.

AIM: The molecular etiology of pelvic organ prolapse (POP) is complex and not well understood. We compared the expression/activity of extracellular matrix (ECM)-processing (procollagen I N-proteinase/ a disintegrin and metalloproteinase with thrombospondin motifs [ADAMTS]-2,-3,-14) and ECM-degrading (matrix metalloproteinase [MMP]-1, -2, -7, -8, -9, -12) enzymes and their natural tissue inhibitors (tissue inhibitors of metalloproteinase [TIMP]-1,-2,-3,-4) in vaginal tissues from premenopausal women with advanced POP (POP-Q stage ≥ 3) and asymptomatic controls (POP-Q = 0). STUDY DESIGN: We sampled the anterior vaginal wall of 36 premenopausal women (17 patients with POP and 19 controls) undergoing total hysterectomy. Exclusion criteria include steroid therapy, malignancy, previous pelvic surgery, and connective tissue diseases. Total RNAs and proteins were quantified by real-time polymerase chain reaction, immunoblotting, and Luminex assay; MMPs activity was analyzed by zymography and tissue localization by immunohistochemistry. RESULTS: The MMP-2 gelatinase activity as well as expression of 58-kDa isoform of ADAMTS-2 was upregulated in patients with POP, irrespective of menstrual phase status, secretory or proliferative, when compared to controls (P < .05). The TIMP-1-4 gene and TIMP-1 protein expression were significantly (P < .05) reduced, whereas protein expression of MMP-12 (pro and active forms) was significantly increased in vaginal biopsies of patients with POP in the proliferative phase of the menstrual cycle compared to corresponding controls. Analyses of MMP-12, TIMP-1, and ADAMTS-2 tissue immunostaining indicate similar localization in the vaginal specimens from control and patients with POP. CONCLUSION: Expression of ECM-remodeling proteins is altered in the vagina of premenopausal patients with severe POP. We speculate that dysregulation of MMP/TIMP complexes and ADAMTS-2 proteins may cause connective tissue defects, which result in weakened vaginal wall support and POP development.

Outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape insertion, and transobturator tape insertion in women with recurrent stress urinary incontinence.

OBJECTIVE: Although the surgical treatment of primary stress urinary incontinence (SUI) has been well studied, the optimal treatment of persistent or recurrent SUI represents a significant challenge to the surgeon, and there are limited relevant published data. The aim of this study was to document outcome data for various surgical techniques used at our centre for the treatment of recurrent SUI, and to assess the immediate and long-term complications associated with these procedures. METHODS: This retrospective study assessed the outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape (TVT) insertion, and transobturator tape (TOT) insertion in the treatment of recurrent SUI in women. Data collected included patient demographics, urodynamic data, postoperative subjective cure and objective cure (negative cough stress test), and intraoperative and postoperative complications. RESULTS: Forty-six women with recurrent SUI were included in the study: 24 had had laparoscopic two-team sling procedures, 15 had had TVT insertion, and 7 had had TOT insertion. For each procedure, objective cure rates were 91.7%, 73.3%, and 85.7%, respectively, and subjective cure rates were 79.2%, 60%, and 57.1% respectively. In the laparoscopic two-team sling group, one woman developed an infected hematoma and one required surgery for a small bowel obstruction. CONCLUSION: The laparoscopic two-team sling procedure or TVT or TOT insertion may be used in experienced hands for surgical management of patients with recurrent stress urinary incontinence. We found no statistically significant differences in outcomes between the three groups, possibly because of the small sample size. Larger sample size and longer follow-up within prospective randomized trials are warranted to identify any possible differences.

Objectif : Bien que la prise en charge chirurgicale de l'incontinence urinaire à l'effort primaire (IUE) ait été bien étudiée, la prise en charge optimale de l'IUE persistante ou récurrente constitue un défi considérable pour le chirurgien et les données publiées pertinentes sont limitées. Cette étude avait pour but de documenter les données quant aux issues de diverses techniques chirurgicales utilisées dans notre centre pour la prise en charge de l'IUE récurrente, ainsi que d'évaluer les complications immédiates et à long terme étant associées à ces interventions. Méthodes : Cette étude rétrospective a évalué l'issue de l'intervention laparoscopique de fronde à deux équipes, de l'insertion d'une bandelette vaginale sans tension (TVT) et de l'insertion d'une bandelette transobturatrice (TOT) dans la prise en charge de l'IUE récurrente chez des femmes. Parmi les données recueillies, on trouvait les caractéristiques démographiques des patientes, les données urodynamiques, la guérison postopératoire subjective et la guérison objective (test à la toux négatif), ainsi que les complications peropératoires et postopératoires. Résultats : Quarante-six femmes présentant une IUE récurrente ont été admises à l'étude : 24 d'entre elles ont subi une intervention laparoscopique de fronde à deux équipes, 15 ont subi une insertion de TVT et 7 ont subi une insertion de TOT. Les taux de guérison objective ont été de 91,7 %, de 73,3 % et de 85,7 %, respectivement, tandis que les taux de guérison subjective ont été de 79,2 %, de 60 % et de 57,1 %, respectivement. Au sein du groupe « intervention laparoscopique de fronde à deux équipes ¼, une des participantes en est venue à présenter un hématome infecté, tandis qu'une autre a nécessité une chirurgie en raison d'une occlusion de l'intestin grêle. Conclusion : L'intervention laparoscopique de fronde à deux équipes ou l'insertion d'une TVT ou d'une TOT peuvent être utilisées par des praticiens expérimentés pour assurer la prise en charge chirurgicale des patientes qui présentent une incontinence urinaire à l'effort récurrente. Nous n'avons constaté aucune différence significative sur le plan statistique en matière d'issues entre ces trois groupes, et ce, peut-être en raison de la faible envergure de l'échantillon. La tenue d'essais randomisés prospectifs comptant des échantillons de plus grande envergure et des suivis prolongés s'avère justifiée aux fins de l'identification de toute différence possible.

Genes responsible for vaginal extracellular matrix metabolism are modulated by women's reproductive cycle and menopause.

OBJECTIVES: To analyze the expression of genes involved in extracellular matrix (ECM) biogenesis and remodeling in vaginal tissue of women with clinically normal pelvic floor support (defined as controls) according to the phase of menstrual cycle and postmenopausal women with and without pelvic organ prolapse (POP). MATERIALS AND METHODS: This study examined the expression of matrix metalloproteinases (MMPs), their tissue inhibitors (TIMPs), and the Lysyl oxidase (LOX) family genes in the anterior vaginal wall of Caucasian women by real-time RT-PCR. Initially, mRNA expression was assessed in premenopausal controls in the secretory (group 1, n = 10) vs. proliferative (group 2, n = 8) phase of menstrual cycle. In addition, we compared premenopausal controls in the proliferative phase (group 2) vs. postmenopausal controls (group 3, n = 5). Finally, we analyzed postmenopausal controls (group 3) vs. postmenopausal women with advanced POP (group 4, n = 13). RESULTS: According to the phase of menstrual cycle, MMP1 was significantly reduced (p = 0.003), whereas the expression of TIMP1 and LOXL4 was significantly up-regulated during proliferative phase (both p < 0.01) when compared to the secretory phase in premenopausal control women. Regarding menopausal status/ageing, all MMPs were down-regulated, while TIMP3, TIMP4 and LOXL2 were significantly up-regulated in postmenopausal control women when compared to premenopausal controls (p = 0.005, p = 0.01 and p < 0.001, correspondingly). TIMP4 and LOXL2 mRNA levels were significantly decreased in postmenopausal POP patients compared to asymptomatic postmenopausal controls (p < 0.01 for both). CONCLUSIONS: Our results indicate that ovarian cycle and age-related changes influence the expression of genes encoding proteins responsible for ECM metabolism in human vagina. Moreover, POP is associated with alteration in vaginal ECM components after menopause.