The Incidence of Pelvic and Low Back Pain in Patients with Pelvic Organ Prolapse.

INTRODUCTION AND HYPOTHESIS: To define the prevalence and incidence of pelvic/low back pain in patients with pelvic organ prolapse (POP). METHODS: Patients presenting for POP to three urogynecology centers in the US, UK, and Chile were enrolled in an IRB-approved cross-sectional study assessing pain, GU, GI and sexual function symptoms. For prevalence, symptoms were noted as present if the participant recorded the symptom and reported the degree of bother as "somewhat," "a moderate amount," or "a lot." For incidence, participants were queried if the symptom's onset concurred with the POP. We also queried if they perceived the symptom was worsened by their POP. RESULTS: Two hundred five participants were recruited: 100 from the US, 46 from the UK, and 59 from Chile. One US participant was excluded due a missing examination. The prevalence of pelvic pain was 42%. Seventy-three percent of these participants reported the onset of pelvic pain coinciding with prolapse onset, and 81% endorsed worsening pelvic pain with POP. The prevalence of low back pain was 46%, with 30% reporting the onset coincided with the onset of POP and 44% responded that prolapse worsened their pain. CONCLUSION: A higher proportion of participants than expected endorsed pelvic/low back pain. Among patients with pelvic pain, the majority experienced symptom onset with POP onset and a worsening of pain with POP. While roughly half of participants reported low back pain; a minority correlated this to their POP. These findings highlight a high incidence of pelvic pain, challenging the perception of POP as a painless condition.

Central Sensitisation Syndrome: A Frequent Finding in Women with Pelvic Floor Symptoms Without Evident Urogenital Prolapse.

INTRODUCTION AND HYPOTHESIS: Women with central sensitisation syndrome (CSS) experience poorer subjective post-operative outcomes even after successful pelvic floor reconstruction. This study tests the hypothesis that women with pelvic floor symptoms (PFS) without relevant pelvic organ prolapse (POP), are more likely to have CSS. METHODS: A questionnaire was sent to women who participated in the POP-UP study in 2017. The POP-UP study evaluated POP in 247 women 16 years after laparoscopic or vaginal hysterectomy. POP-Q data and Pelvic Floor Distress Inventory (PFDI-20) results were used and supplemented with CSS-specific questionnaires. A Central Sensitisation Inventory (CSI) score above 40 implicates CSS. Women were divided into groups based on POP beyond the hymen in relation to the PFDI-20 score. Outcomes of women with PFS and without POP (called 'group 1') were compared with the rest of the cohort (groups 2-4; women without PFS and/or with POP). RESULTS: A total of 136 women were included in the analysis. A CSI score above 40 was present in 16 out of 42 women of group 1 (37%) versus 11 out of 93 women of groups 2-4 (12%), p < 0.0001. Passive coping was more prevalent in group 1 (p = 0.039), and more deviations in somatisation, depression, anxiety and distress were found in group 1 (p values of < 0.0001, 0.018, 0.003 and 0.002 respectively). CONCLUSIONS: This study suggests that CSS might be more prevalent in women with PFS without relevant POP. More awareness of CSS and valid individual counselling may overcome unnecessary surgery for POP and help in setting realistic expectations.

Toward Patient-specific Pessary to Manage Pelvic Organ Prolapse: Design and Simulation.

This study proposed a novel design and personalized approach to developing an intra-vaginal device, also known as a pessary, for the treatment of Pelvic Organ Prolapse (POP). Although POP is likely to have a more diverse dynamic than other health conditions in women, it is currently treated as a "one-shape-fits-all" problem in all cases. Pessaries are conservative devices inserted into the vagina to support its internal structure and predominantly come in a ring shape design. Failure rates as high as 50% within the first year of use have been attributed to the poor design of these pessaries; with symptoms such as irritation, bleeding, and lacerations felt by most users. To address this problem, a new base shape design was proposed and its deformation was examined using Finite Element Analysis (FEA). Based on the anatomical measurements of each patient, the base design can be adjusted accordingly. To demonstrate the effectiveness of the proposed design, a comparative study was conducted with the most commonly used support pessary, also known as the ring pessary. In order to model the large deformation of the pessaries, the hyperelastic constitutive law (Yeoh model) was fitted to the available stress-strain data of SIL 30 (a silicone urethane resin supplied by Carbon Inc.). The results showed that re-directing the reaction forces of the pessary towards the lateral walls, supported by the pelvic bones, could decrease the overall displacement of the pessaries, and provide effective symptomatic relief thereby, delaying or preventing surgical procedures.Clinical relevance- There is a clear clinical need to develop a more effective conservative therapy for managing POP. The personalized pessaries proposed in this paper can be an effective method for providing symptomatic relief and avoiding displacement, compared to the currently available devices on the market. Made-to-measure for each patient, the devices are anatomically suited and can be adjusted throughout a patient's treatment plan to allow for higher compliance and overall success rate.

4D DIA-PRM proteomic study identifying modulated pathways and biomarkers associated with pelvic organ prolapse.

Pelvic organ prolapse (POP) is a highly disabling condition that negatively affects the quality of life of millions of women worldwide. However, the underlying mechanisms associated with the development and progression of the disease remain poorly understood. Here, an untargeted four-dimensional data-independent acquisition (4D DIA)-based proteomics approach was applied to vaginal wall tissue samples from POP (n = 19) and control (n = 8) patients to identify potential diagnostic biomarker(s) for POP and examine the molecular mechanisms underlying the disease. Of the 5713 tissue proteins that were detected, 1957 proteins were significantly changed in POP patients. Further bioinformatics analysis revealed that multiple biological processes including protein digestion & absorption, retrograde endocannabinoid signaling, tyrosine metabolism, and nucleotide metabolism were significantly enriched and associated with the pathogenesis of POP. Interestingly, 16 of these differentially expressed proteins associated with four pathways were also identified by targeted parallel reaction monitoring (PRM) proteomics analysis on the same 27 tissue samples. Changes in 94 % (15/16) of these proteins were consistent with the 4D DIA data. Furthermore, most proteins displayed good diagnostic accuracy with high area under the curve (AUC) values (AUC＞0.8). Specifically, five proteins including ELN, COL6A2, ENTPD1, AOC3, and COX7A2 distinguished between POP and control patients with very high accuracy (AUC ≥ 0.95) in both 4D DIA and PRM analyses, and may therefore be potential diagnostic biomarkers for POP. In summary, the present study not only provided several potential biomarker(s) for effective POP diagnosis, but extended our knowledge of the key regulatory pathways associated with the disease.

International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction.

INTRODUCTION AND HYPOTHESIS: This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction. METHODS: An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed. RESULTS: The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP. CONCLUSIONS: The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

Evaluation of sexual function and vaginal prolapse after radical cystectomy in women: a study to explore an under-evaluated problem.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate sexual function, vaginal prolapse, and quality of life (QoL) in women after radical cystectomy (RC) using validated questionnaires and pelvic organ prolapse quantification (POP-Q) measurement. METHODS: Female bladder cancer patients who underwent RC at our tertiary care center were included (January 2008 to March 2022). Patients received three validated questionnaires (International Consultation on Incontinence Questionnaire Vaginal Symptoms [ICIQ-VS] Part A, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA revised [PISQ], European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC] C30/BLM30). Patients who consented were examined with vaginal POP-Q measurement. RESULTS: Out of 322 patients, 193 were still alive, 54 patients were lost to follow-up, and 43 were excluded, resulting in 96 patients who received the questionnaire. Finally, 35 patients were included, of whom 17 patients consented to vaginal examination. Complaints due to vaginal symptoms were low (ICIQ-VS 6.17 + 5.37). Sexual activity was reported by 12 patients (34.3%); 23 patients (65.71%) were not sexually active. No apical prolapse was found in POP-Q measurement; 6 patients (35.3%) had anterior, and 14 patients (82.4%) posterior prolapse; the highest prolapse stage was 2. No significant differences were found regarding POP stages, sexual function, and QoL (all p > 0.05) when comparing continent and incontinent urinary diversions. Comparing the vaginal approach (no sparing vs sparing), significant differences were found in only two PISQ subscales (significantly higher scores after vagina sparing, p = 0.01 and p = 0.02). CONCLUSIONS: The type of urinary diversion, POP-Q stages, and tumor stages did not show significant differences regarding sexual function, QoL, and prolapse complaints in women after RC, whereas a vagina- sparing approach showed significant differences only in two subscales without clinical relevance.

Effectiveness of Laparoscopic Pectopexy for Pelvic Organ Prolapse Compared with Laparoscopic Sacrocolpopexy.

STUDY OBJECTIVE: To evaluate the clinical benefits of laparoscopic pectopexy vs laparoscopic sacrocolpopexy in women with pelvic organ prolapse (POP). DESIGN: Prospective cohort study. SETTING: A tertiary hospital. PATIENTS: We included 203 patients with POP. INTERVENTIONS: Laparoscopic pectopexy or laparoscopic sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: Anatomic effectiveness was measured using the POP Quantification system, both before and after operation. Functional recovery effectiveness was evaluated using complications and recurrence rates within 1 year. Quality of life was assessed by the Pelvic Floor Distress Inventory-20 and Incontinence Quality of Life questionnaires at enrollment and postoperative months 3, 6, and 12. Comparisons between groups were performed using t test, chi-square test, and mixed-effects model with repeated measures. The analysis included 203 eligible patients (sacrocolpopexy, 101; pectopexy, 102). The proportion of robotic-assisted surgeries was lower in the pectopexy group than in the sacrocolpopexy group (15.7% vs 41.6%, p <.001). The average operation time of pectopexy was shorter than that of sacrocolpopexy (174.2 vs 187.7 minutes) with a mean difference of 13.5 minutes (95% confidence interval, 3.9-23.0; p = .006). Differences of intraoperative blood loss, length of hospital stay, and postoperative 7-day complications between groups were not significant. Anatomic successes were obtained in both groups with similar improvement in POP Quantification scores. The rate of urinary symptoms recurrence was higher in the pectopexy group (13.7%) than in the sacrocolpopexy group (5.0%) at the 1-year follow-up (odds ratio, 3.1; 95% confidence interval, 1.1-8.8, p = .032). The Pelvic Floor Distress Inventory-20 and Incontinence Quality of Life scores were better improved at postoperative months 3, 6, and 12 for laparoscopic pectopexy than for sacrocolpopexy. CONCLUSION: Laparoscopic pectopexy revealed comparable anatomic success, shorter operation time, and better improvement in quality of life scores of prolapse, colorectal-anal, and urinary symptoms at 1-year follow-up, possibly being an alternative when sacrocolpopexy is not practicable. However, clinicians should pay more attention to the recurrence of urinary symptoms after pectopexy.

Reliability and validity of the Sidaamu Afoo version of the pelvic organ prolapse symptom score questionnaire.

BACKGROUND: Both for clinical and research purposes, it is critical that clinicians and researchers use a tool that is trans-culturally adapted and tested for its psychometric properties. The English version of the Pelvic Organ Prolapse Symptom Score (POP-SS) questionnaire was developed in 2000. Since then it has been translated into other languages and verified. However, the tool has not been adapted for use in Sidaamu Afoo language in the Sidama Region of Ethiopia. OBJECTIVE: This study aimed to translate and adapt the Pelvic Organ Prolapse Symptom Score questionnaire into Sidaamu Afoo and evaluate its psychometric properties. METHODS: A total of 100 women with symptomatic prolapse completed version-2 of the POP-SS questionnaire during the first round of interviews, and 61 of them completed the questionnaire during the second round of interviews (to establish the test-retest reliability). We adapted the scale translation process recommended by Beaton and his colleagues. The content validity was assessed using the content validity index and the construct validity was done based on exploratory factor analysis using the principal component analysis model. The criterion validity was evaluated by using the Kruskal-Wallis test based on stages of the prolapse established via pelvic examination. The internal consistency reliability of the scale was assessed using Cronbach's alpha value, and test-retest reliability was evaluated using the intraclass correlation coefficient. RESULTS: The questionnaire was successfully translated to Sidaamu Afoo, and achieved a good content validity index (0.88), high internal consistency (Cronbach's alpha of 0.79), and test-retest reliability (an intraclass correlation coefficient of 0.83). The exploratory factor analysis revealed two factors based on an eigenvalue of 1. The two factors explained 70.6% of the common variance, and each item loaded well (0.61 to 0.92) to its corresponding factor. There is a significant difference in the median score of prolapse symptoms across different stages of prolapse (Kruskal-Wallis χ2, 17.5, p < 0.001). CONCLUSION: The Sidaamu Afoo version of the POP-SS tool is valid and reliable. Further studies that involve a balanced number of women in each stage of prolapse are needed to avoid the ceiling and floor effects.

Clean-Catch Urine Specimen More Likely to Be Contaminated After Vaginal Surgery for Pelvic Organ Prolapse.

IMPORTANCE: Accurate diagnosis of urinary tract infection after pelvic organ prolapse (POP) surgery is essential to postoperative care. OBJECTIVE: Our aim was to determine the agreement between the urinalysis of a clean-catch versus a straight catheter urine specimen in women who underwent vaginal surgery for POP. STUDY DESIGN: This was a cross-sectional study evaluating patients after vaginal surgery for POP. A clean-catch and straight catheter urine specimen were collected at routine postoperative appointments. Routine urinalyses and urine cultures were performed for all patients. A urine culture yielding mixed urogenital flora (which includes Lactobacillus species), coagulase-negative staphylococci, and Streptococcus species was considered a contaminated result. The agreement between the characteristics of urinalysis obtained via the clean catch versus the straight catheter at 3 weeks postoperatively was evaluated using weighted κ statistic. RESULTS: Fifty-nine participants enrolled. The agreement between the characteristics of urinalysis obtained via the clean catch versus the straight catheter was poor (κ = 0.018). The urine culture was more likely to be contaminated from the clean-catch urine specimen than from the straight catheter urine specimen (53.7% vs 23.1%).The positive and negative predictive values of leukocyte esterase on clean catch were 22.6% and 100%, respectively. CONCLUSIONS: Diagnosing urinary tract infection based on contaminated urinalyses may lead to antibiotic overuse and misdiagnosis of postoperative complications. Our results can help educate health care partners and discourage the use of clean-catch urine specimens when assessing women who have recently undergone vaginal surgery.

An evaluation of pelvic organ prolapses in perimenopausal and menopausal Chinese females.

OBJECTIVE: The aim of the study was to evaluate the prevalence of pelvic organ prolapse (POP) and correlate the various factors including, but not limited to, educational status, socio-economic condition, body mass index (BMI), menstrual history, with the status and severity of POP. PATIENTS AND METHODS: A retrospective cross-sectional study was conducted between August 2021 and September 2022 and suspected patients of POP were considered from the outpatient Department of Gynecology and Obstetrics. The study has mainly used 3 indicators of socio-economic status, namely, occupation, education, and income. These factors were correlated and statistically analyzed with that of POP. RESULTS: The study findings revealed that there are more symptomatic patients who are illiterate as compared to asymptomatic POP and with increasing education status, there is a decrease in symptomatic POP patients (p<0.05). Also, there is a significant proportion of symptomatic POP patients in the lower class and lower middle class as compared to asymptomatic patients in each class, respectively (p<0.05). It also found that micturition difficulty and vaginal bulging are significantly correlated with the stages of POP (p<0.05). CONCLUSIONS: Educational status and socio-economic condition are significant indicators of the presence of symptoms or severity of POP. The study further concluded that menopausal females have more symptomatic POP as compared to pre-menopausal females.

Exame físico em ginecologia / Physical examination in gynecology

O exame físico na prática ginecológica diuturna é o sustentáculo de uma perspectiva diagnóstica com vistas a uma abordagem individualizada, oportuna e humanizada da paciente. Lança mão de técnica semiótica clássica, inicialmente, após avaliação de sinais vitais, minuciosa inspeção ectoscópica, seguida de exame físico especial. E deverá ser realizado em ambiente adequadíssimo, sem nenhuma improvisação e ou adaptações não compatíveis, com a importância e a segurança garantidas por um exame físico de boa qualidade. O exame físico de mamas tem como objetivo primordial a identificação de nódulos mamários e, eventualmente, de tumores localmente avançados; e relativa tranquilidade é assegurada às pacientes quando ele é considerado normal. O exame físico vulvar permite a identificação de prolapso de órgãos pélvicos, neoplasia intraepitelial e/ou invasiva vulvar e distúrbios de desenvolvimento sexual, além de oferecer subsídios para a propedêutica da vulvodínea, sendo, principalmente, uma oportunidade para o diagnóstico em dermatologia vulvar, mesmo a vulva correspondendo a apenas 1% da pele feminina. O exame especular, um clássico da ginecologia, é indispensável para a triagem do câncer de colo uterino. Por fim, o toque genital, a despeito de sua subjetividade, permite a avaliação dos órgãos genitais internos.

Physical examination in daytime gynecological practice is the mainstay of a diagnostic perspective with a view to an individualized, timely and humanized approach to the patient; resorting to the classical semiotic technique, initially, after assessing vital signs, a thorough ectoscopic inspection, followed by a special physical examination; which should be carried out in a very suitable environment, without any improvisation or adaptations that are not compatible with the importance and safety guaranteed by a good quality physical examination. The primary objective of the physical examination of the breasts is to identify breast nodules and possibly locally advanced tumors; in addition to relative tranquility, assured to patients, when the respective exam is considered normal. Vulvar physical examination allows the identification of pelvic organ prolapse; vulvar intraepithelial and/or invasive neoplasia; sexual development disorders; in addition to offering subsidies for the propaedeutics of vulvodynia; and, above all, it is an opportunity for diagnosis in vulvar dermatology, even though the vulva accounts for only 1% of female skin. Specular examination, a classic in gynecology, is essential for screening for cervical cancer. Finally, the genital touch which, despite its subjectivity, allows the evaluation of the internal genital organs.

3D ultrasound strain imaging of puborectal muscle with and without unilateral avulsion.

INTRODUCTION AND HYPOTHESIS: The puborectal muscle (PRM), one of the female pelvic floor (PF) muscles, can get damaged during vaginal delivery, leading to disorders such as pelvic organ prolapse. Current diagnosis involves ultrasound (US) imaging of the female PF muscles, but functional information is limited. Previously, we developed a method for strain imaging of the PRM from US images in order to obtain functional information. In this article, we hypothesize that strain in the PRM would differ from intact to the avulsed end. METHODS: We calculated strain in PRMs at maximum contraction, along their muscle fiber direction, from US images of two groups of women, which consisted of women with intact (n1 = 8) and avulsed PRMs (unilateral) (n2 = 10). Normalized strain ratios between both ends of the PRM (avulsed or intact) and the mid region were calculated. Subsequently, the difference in ratio between the avulsed and intact PRMs was determined. RESULTS: We observe from the obtained results that the contraction/strain pattern of intact and undamaged PRMs is different from PRMs with unilateral avulsion. Normalized strain ratios between avulsed and intact PRMs were statistically significant (p = 0.04). CONCLUSION: In this pilot study, we were able to show that US strain imaging of PRMs can show differences between intact PRMs and PRMs with unilateral avulsion.

Validation of the short forms of the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire in Estonian.

INTRODUCTION AND HYPOTHESIS: Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) are reliable instruments for evaluating the quality of life in women with pelvic organ prolapse (POP). They have been translated and validated in many languages. The study was aimed at validating the Estonian translations of the PFDI-20 and PFIQ-7 tools. METHODS: The questionnaires were translated into Estonian using a multistep translation method. A total of 132 women were enrolled: patients with diagnosed POP (n=57) were allocated to test-retest reliability analyses, and those with no POP signs (n=88) completed the questionnaire only once. The total scores of questionnaires and their subscales of both patient and reference groups were compared. Item response rate, floor and ceiling effects, corrected item-total correlations, internal consistency, and convergent and discriminant validity were analyzed. The study was approved by the Ethics Committee of Human Research of the University Clinic of Tartu, Estonia, and informed consent was obtained from each participant. RESULTS: The translated questionnaires demonstrated good internal consistency (Cronbach's α values 0.77-0.93). The item response rate was 99%. Intra-class correlations (ICC) were strong for PFDI-20 and PFIQ-7 and their subscales ranged from 0.86 to 0.96. Construct validity of the tools demonstrated by manyfold higher scores among patients with POP compared with women without POP (p<0.0001). CONCLUSIONS: The Estonian versions of the PFDI-20 and PFIQ-7 tools are reliable and valid instruments for assessing the quality of life in women with POP.

Dynamic, High-Fidelity, 3-Dimensional Pelvic Model Improves Education on Pelvic Organ Prolapse and the Pelvic Organ Prolapse Quantification System and Interest in Urogynecology.

IMPORTANCE: Pelvic organ prolapse (POP) affects millions of women globally. Still, medical students and obstetrics and gynecology residents gain minimal exposure to POP during training. OBJECTIVES: Our goal was to increase exposure to POP by creating a high-fidelity, dynamic, 3-dimensional pelvic model of prolapse and using it to teach through didactic learning sessions. STUDY DESIGN: This was a prospective cohort study from November 2021 to July 2022. Presession and postsession surveys were administered to assess for change in POP knowledge both subjectively and objectively. Statistical analysis was performed using the Wilcoxon signed-rank test with a P value of 0.05 denoting significance. RESULTS: Thirty-three learners participated in the study, including 18 residents and 15 medical students. Most participants had interacted with urogynecologists and had seen at least 1 patient with POP. Fewer participants had received prior education on POP and the Pelvic Organ Prolapse Quantification (POP-Q) examination, witnessed or performed a POP-Q examination, or participated in POP surgical procedures. After learning with the model, comfort with identifying POP doubled (P < 0.001), the ability to understand the POP-Q examination quadrupled (P < 0.001), the ability to perform a POP-Q examination tripled (P < 0.001), and the ability to teach a POP-Q examination doubled (P < 0.001). The median score on a multiple-choice knowledge assessment increased by 40% (P < 0.001). Learners felt that the pelvic model was an effective teaching tool that increased interest in the field of urogynecology. CONCLUSIONS: Using a high-fidelity, dynamic model in didactic sessions enhances education about POP and the POP-Q system and should be used to improve learner exposure and experience.

Evaluation and treatment of pelvic organ prolapse.

Pelvic organ prolapse is a common condition that can have a large impact on a patient's quality of life. Patients with prolapse may present with a vaginal bulge or pressure, bladder, bowel, or sexual symptoms. The diagnosis is confirmed on physical examination which may show descent of the anterior vaginal wall, vaginal apex (cervix/uterus or vaginal cuff in those with a prior hysterectomy), posterior vaginal wall, or a combination of these. Patients with asymptomatic prolapse can typically be reassured that it may be managed with observation, though might gradually progress with time. In patients with symptomatic prolapse, management options include conservative measures, pessary use, or surgical intervention. Pessaries can successfully be fitted for most patients that prefer this line of therapy. Surgical interventions include native tissue transvaginal surgeries or a transabdominal (laparoscopic or robotic) approach with use of polypropylene mesh. The choice of surgical procedure includes consideration of an individual's medical and surgical history, physical exam findings, differences in the risks and durability of the operations, and the patient's preference. Ultimately, the surgical plan is based on shared decision making with the patient to best achieve their treatment goals. In this article we will review pertinent clinical considerations in the diagnosis, evaluation, and management of pelvic organ prolapse.

Multimodal measurements of levator bowl volume in nulligravid asymptomatic women: endovaginal ultrasound versus MRI.

INTRODUCTION AND HYPOTHESIS: Measurements of levator bowl volume using advanced imaging, may be predictive of pelvic floor muscle function. The aim of this study was to compare the volume of the levator bowl using both magnetic resonance imaging (MRI) and endovaginal ultrasound (EVU) of healthy asymptomatic women. METHODS: All participants underwent a comprehensive interview including completion of the Pelvic Floor Distress Inventory Questionnaire-20 questionnaire, pelvic examination with a pelvic organ prolapse quantification evaluation, MRI, and EVU. The pelvic floor was segmented using Slicer and the MRI segmentations were trimmed using two methods: soft-tissue landmarks and the field of view (FOV) of the ultrasound volume. The levator bowl volume of the 3D segmented shapes was measured using Blender's 3D printing toolkit. Normality was tested using the Shapiro-Wilks test and comparisons were made using self-paired t tests. RESULTS: The final analysis included 19 patients. Levator bowl volume measured via MRI was larger than that measured in EVU (46.1 ± 7.9 cm3 vs 27.4 ± 5.9 cm3, p<0.001). Reducing the FOV of the MRI to that of EVU caused the MRI volume to be much closer to the EVU volume (35.5 ± 3.3 cm3 vs 27.4 ± 5.9 cm3, p<0.001); however, it remained significantly larger. CONCLUSION: Levator bowl volume measured using MRI was larger than that measured using EVU no matter the method of delineation of the levator muscles. Although EVU is safe, cheap, and easy to perform, it captures a smaller volume of levator bowel than MRI.

Australian Pelvic Floor Questionnaire: translation, cultural adaptation, and validation.

INTRODUCTION AND HYPOTHESIS: The aim was to translate, culturally adapt, and validate the APFQ (Australian Pelvic Floor Questionnaire) for the population of Brazilian pregnant and postpartum women. METHODS: The translation and validation of the APFQ were performed according to Beaton's guideline recommendations, with a sample of 150 patients (75 pregnant, 75 postpartum). Cronbach's alpha assessed the scale's internal consistency and reproducibility with the intraclass correlation coefficient (ICC). To analyze the construct validity, two questionnaires were applied, and the Spearman correlation was performed. Confirmatory factor analysis (CFA) was executed to assess the fit of the data to the theoretical model. The ability to generate diagnosis was analyzed by sensitivity and specificity. RESULTS: Only 1% of the sample scored in the prolapse domain, so it was removed from the validation analyses. Cronbach's alpha values greater than 0.70 were obtained for the bladder and bowel domains, and 0.69 for sexual function. As for reproducibility, the ICC was greater than 0.75 for all domains. Spearman's correlation was good for bowel (r=0.74), moderate for bladder (r=0.58), and poor for sexual function (r=0.23). CFA results showed a non-optimal adherence: despite the Chi-squared value being significant (p<0.001), the CMIN- which is the adherence of the data to the model- value is less than 3. Sensitivity above 80% was obtained, whereas specificity of 43%, 16%, and 12% was obtained for bowel, bladder, and sexual functions respectively. CONCLUSION: The APFQ was translated, culturally adapted, and validated for Brazilian pregnant and postpartum women. It showed good indexes of internal consistency, construct validity, reproducibility, and sensitivity. However, the prolapse domain could not be validated.

The Value of Preoperative Multichannel Urodynamic Testing for Detecting Occult Stress Urinary Incontinence in Women Undergoing Prolapse Repair Surgery.

BACKGROUND: Diagnosing occult stress urinary incontinence (OSUI) prior to surgical intervention for pelvic organ prolapse (POP) repair may allow for adding an anti-incontinence procedure and thus prevent postoperative SUI. OBJECTIVES: To compare preoperative detection rates for OSUI by either a multichannel urodynamic investigation or by a plain pelvic examination. METHODS: We retrospectively evaluated the medical charts of all women who underwent urodynamic investigation prior to surgical repair of advanced POP at our institution between 1 January 2006 and 31 December 2012. RESULTS: In total, 720 women underwent surgical POP repair during the study period, of whom 54 (7.5%) were diagnosed with OSUI preoperatively. Of these patients, 54 (100%) were detected by multichannel urodynamic investigation while only 27 (50%) were detected by a plain pelvic examination (P = 0.001). Bladder fullness during the pelvic examination was associated with higher detection rates for OSUI (P = 0.001). Women with OSUI who underwent concomitant tension-free vaginal tape and POP repair procedures did not develop de novo SUI or obstructive voiding symptoms (OVS) postoperatively. CONCLUSIONS: Preoperative multichannel urodynamic investigation has significantly higher detection rates for OSUI than a plain pelvic examination. Utilizing this modality resulted in no cases of de novo SUI or OVS postoperatively.

Clinical assessment of pelvic organ prolapse by consecutive cough maneuver.

INTRODUCTION AND HYPOTHESIS: Staging of pelvic organ prolapse (POP) is important in clinical practice and research. Pelvic organ descent on Valsalva can be confounded by levator co-activation, which may be avoided by assessment on coughing. We evaluated the performance of a three consecutive coughs maneuver in the assessment of POP compared with standardised 6-second Valsalva. METHODS: This was a retrospective observational study carried out in women attending a tertiary urogynaecological service in 2017-2019. Patients underwent a standardised interview and clinical examination. Clinical assessment was performed twice, with both 6-s Valsalva and three consecutive coughs performed in random order. Main outcomes were Ba, C and Bp as defined by Pelvic Organ Prolapse-Quantification (POP-Q). Association between coordinates and prolapse symptoms was investigated with receiver-operating characteristic (ROC) statistics. RESULTS: Datasets of 855 women were analysed. POP symptoms were reported by 447 patients (52%) with a mean bother of 6.1 (SD 3.0). On clinical assessment, relevant prolapse was found in 716 (84%) patients on Valsalva and in 730 (85%) on coughing (p=0.109). Clinically relevant prolapse in the apical compartment was more likely to be detected on Valsalva (p<0.0001). Mean POP-Q measurements were not significantly different between maneuvers, except for Ba (p=0.004). ROC curve analysis yielded an area under the curve of 0.74 (95% CI, 0.70-0.77) for maximum POP-Q stage on Valsalva and 0.72 (95% CI, 0.69-0.75) after three consecutive coughs, with a similar performance of both maneuvers in predicting prolapse symptoms (p=0.95). CONCLUSIONS: Clinical assessment of POP by consecutive coughing seems complementary to standardised Valsalva, especially if Valsalva performance is poor.

Quality of life among women with a diagnosis of pelvic organ prolapse at Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Northwest Ethiopia: an institutional based cross-sectional study.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse is among the most common gynecologic problems worldwide. It greatly influences women's quality of life. However, research regarding the effect of pelvic organ prolapse on quality of life is limited in our study area. METHODS: An institutional-based study design among women with the diagnosis of pelvic organ prolapse at Felege Hiwot Comprehensive Specialized Hospital was employed from May to July 2018. Interviewer-administered questionnaire and Prolapse Quality of Life assessment tool were used to collect data. Gynecologic speculum examination was done to collect objective data. Data were entered into Epi info version 7 and then exported in to SPSS, version 20.0, for analysis. Descriptive statistics and logistic regression were used. All the statistical tests were significant at P < 0.05. RESULTS: The average prolapse quality of life score was 48.35 ± 22.75 SD. The physical limitation (score: 69.83 ± 28.77 SD) and general health perception (score: 67.39 ± 20.26 SD) domains were the most affected life domains. Younger age (AOR = 3.02 [95% CI: 1.22-7.45]), being illiterate (AOR = 3.52 [95% CI: 1.12-11.10]), and having stage IV POP (AOR = 2.84 [95% CI: 1.16-7.00]) were associated with lower quality of life. CONCLUSIONS: The QOL score showed huge variability among the study participants. The physical limitation and general health perception domains were most affected. Being illiterate, being < 35 years old, and having stage IV pelvic organ prolapse were the factors associated with lower quality of life.