Trans-labial or introital ultrasounds for midurethral slings.

Stress urinary incontinence is common in adult women. The use of introital or trans-labial ultrasound can help the surgeon (urologist or gynecologist) to better assess the type of incontinence the patient presents in order to guide him in the management of the patient. Often, surgical treatment with a mid-urethral sling (MSU) placement can be chosen in case of failure of non-invasive therapies (such as local estrogen or physical therapy) and if the clinical examination shows an urethral hypermobility. The use of ultrasound can help in this choice. Although rare, complications of MSU can sometimes cause disabling symptoms and be difficult to diagnose. Introital or trans-labial ltrasound can help diagnose them. The objective of this work was to describe the realization of ultrasound of stress urinary incontinence before or after the placement of a MSU, in order to make their realization easier for young surgeons which can use them in current practice.

[Mirror survey of patients with urge urinary incontinence and healthcare professionals]. / Enquête miroir auprès de patients et de professionnels de santé portant sur l'incontinence urinaire par urgenturie ou mixte.

BACKGROUND: This survey assessed how much of a taboo surrounds urge or mixed urinary incontinence (UI), through questions to affected patients and healthcare professionals using online questionnaires, with the objective to contrast the patients' perceptions with that of the doctors. METHODS: This quantitative study was preceded by a qualitative phase carried out with general practitioners, specialists, and UI patients. Following these phases, questionnaires were made available on the internet. They covered questions pertaining to perceptions of UI, degree of embarrassment and its consequences, patient-doctor relationship, and treatments. RESULTS: Overall, 310 UI patients of male or female gender participated in the study, as did 101 general practitioners, 50 urologists, and 30 gynecologists. The analysis revealed that 60% of patients felt embarrassment about UI, the condition representing for them a taboo topic similar to cancer. This taboo was shown to be seen further enhanced by doctors. UI was associated with a loss of self-esteem (51%) and restriction to daily life (44%). The patients' answers revealed that UI was only brought up by doctors in 6% of cases, whereas the patient was the first to bring it up in 55%, primarily with their general practitioner (80%). Thus, in 4 out of 10 cases, the issue was not addressed; 49% of patients stated they did not discuss their condition with their partner and 33% did not discuss it with anybody. CONCLUSION: UI is still a major taboo and we have a long way to go to change attitudes. LEVEL OF EVIDENCE: 3.

[Validation of a new self-questionnaire to assess sexuality in patients operated on for urinary incontinence or genital prolapse (Pelvi-Perineal Surgery Sexuality Questionnaire - PPSSQ)]. / Validation d'un nouvel auto-questionnaire d'évaluation de la sexualité chez les patientes opérées d'une incontinence urinaire ou d'un prolapsus génital (Pelvi-Perineal Surgery Sexuality Questionnaire ­ PPSSQ).

INTRODUCTION: The main objective of this study was to validate a new questionnaire evaluating sexual health, in a population of sexually active women or not, who have surgery for stress urinary incontinence or pelvic organ prolapse with or without mesh reinforcement. MATERIAL AND METHODS: After the development of a first version of the questionnaire by members from the main French societies involved in the study of women's sexuality, a linguistic validation of the content of the questionnaire was carried out through semi-structured interviews. Then, a psychometric validation was carried out in a prospective multicenter cohort study. The questionnaire was evaluated in terms of acceptability, quality, dimensionality, internal consistency, temporal stability, sensitivity to changes and construction validity. RESULTS: Linguistic validation was carried out in 25 patients. Psychometric validation was carried out in 297 women (291 with available data) operated on for urinary incontinence by midurethral sling (n=79) or for pelvic organ prolapse by the vaginal route with mesh (n=105), without mesh (n=22) or by laparoscopic sacrocolpopexy (n=85) between January 18, 2013 and January 18, 2016. Within the 288/291 women who had filed the question No. 1 allowing to know their sexual "status", 159 (55%) women were sexually active and 129 (45%) women were not sexually active before surgery. Within the 288 women, 165 had completed the questionnaire preoperatively and at 12 months and 111 had completed the questionnaire at 12 months and 12 months+1 week. The questionnaire was well accepted by the women and of good quality. All the questions were kept, but a change in the order and numbering of the questions had to be made. Two clinically relevant dimensions were identified in this analysis: a "sexual health" dimension comprising 5 questions and a "discomfort and pain" dimension comprising 3 questions. The overall questionnaire and both dimensions had good reliability and moderate to excellent temporal stability. A statistically significant association was demonstrated between question 15 and the improvement reported by PGI-I and the anatomical success rate on POP-Q classification. A strong correlation was found between the "sexual health" score and the total FSFI score. CONCLUSION: The Pelvi-Perineal Surgery Sexuality Questionnaire (PPSSQ) is a 13-question self-questionnaire validated in a population of sexually active women or not, operated on for stress urinary incontinence or pelvic organ prolapse by laparoscopy or vaginal surgery, with or without mesh. LEVEL OF EVIDENCE: 4.

[Use of botulinum toxin A in pelvic floor dysfunctions in the elderly: A review]. / Intérêt de la toxine botulinique A dans le traitement des troubles pelvi-périnéaux de la personne âgée.

INTRODUCTION: The present article is the final report of a multi-disciplinary meeting supported by the GRAPPPA (group for research applied to pelvic floor dysfunctions in the elderly). The objective was to conduct a comprehensive review on the role of botulinum toxin A (BonTA) in the treatment of pelvic floor dysfunctions in the elderly. METHODS: The present article, written as a comprehensive review of the literature, combines data issued from the scientific literature with expert's opinions. Review of the literature was performed using the online bibliographic database MedLine (National Library of Medicine). Regarding intra-detrusor BonTA injections, only articles focusing on elderly patients (>65 yo) were included. Regarding other localizations, given the limited number of data, all articles reporting outcomes of BonTA were included, regardless of studies population age. In case of missing or insufficient data, expert's opinions were formulated. RESULTS: Although, available data are lacking in this specific population, it appears that BonTA could be used in the non-fraily elderly patients to treat overactive bladder or even neurogenic detrusor overactivity, with a success rate comparable to younger population at 3 months (88.9% vs. 91.2%), 6 months (49.4% vs. 52.1%) and 12 months (23.1% vs. 22.3%), as well as a significant decrease in number of voids per day (11.4 vs. 5.29 P<0.001) and in the number of pads per day (4.0 vs. 1.3, P<0.01). Furthermore, BonTA is likely to be offered in the future as a treatment of fecal incontinence and obstructed defecation syndrome symptoms. Concerning bladder outlet obstruction/voiding dysfunction symptoms, intra-urethral sphincter BonTA should not be recommended. CONCLUSION: BonTA injections are of interest in the management of various pelvic floor dysfunctions in the elderly, and its various applications should be better evaluated in this specific population in order to further determine its safety and efficacy.

[Could we perform vaginal mesh surgery for treatment of pelvic organ prolapse in elderly women?] / La chirurgie vaginale prothétique peut-elle être proposée aux patientes âgées de plus de 75 ans ?

INTRODUCTION: Prevalence of pelvic organ prolapse will increase with the aging of the population. Concerning the treatment of pelvic organ prolapse, transvaginal route is often preferred for elderly women. However few data are available concerning transvaginal mesh surgery in this population. The aim of this study was to compare efficiency and complications of transvaginal mesh surgery between women aged over 75 and younger women. MATERIALS AND METHODS: A monocentric, retrospective study included all women who underwent anterior sacrospinous suspension with mesh for treatment of pelvic organ prolapse. The primary endpoint was anatomical success at the last follow-up, defined by a pelvic organ prolapse stage 0 or 1 of POP-Q classification. The secondary endpoints were rate of complications and urinary, colorectal and sexual functional results. RESULTS: We included 329 patients, 69 were under 75 years old and 260 were aged over 75. The median of follow-up was 12 months (IQR: 6). The rate of anatomical success was significantly higher in patients aged over 75: 92% versus 85% in younger patients (P=0.02). However this difference was no more significant in multivariate analysis after inclusion of confusions factors (P=0.82). The rate of perioperative complications was low and similar in the 2 groups even in multivariate analysis. CONCLUSION: Utero-vaginal suspension using bilateral vaginal anterior sacrospinous fixation with mesh seems to achieve at least similar results between women aged more than 75 years and younger women. There is no excess risk of complications in elderly women. LEVEL OF EVIDENCE: 4.

[Cardiovascular adverse effects of antimuscarinics used in the treatment of overactive bladder in the elderly : A review]. / Effets cardio-vasculaires des traitements anticholinergiques à visée vésicale chez la personne âgée : une revue.

AIM: The aim of this study was to review the evidence regarding the cardiovascular effects of urinary anticholinergic drugs in the elderly. METHODS: A literature review was conducted in October 2017 using the Medline/Pubmed database limiting the search to works in English or French. RESULTS: In total, 602 articles between March 1964 and October 2017 have been reported, 60 studies were analyzed, 19 were prospective trials. Geriatric population has a high prevalence of cardiovascular diseases (24.4% of heart diseases on 65-74years and 36.9% on ≥75years). More than 20% of the geriatric population has overactive bladder history and 41.43% of them use of antimuscarinic drugs. Evaluating the cardiovascular adverse effects of antimusarinics in the geriatric population is not easy because of exclusion of high-risk patients in trials. However, serious cardiovascular adverse effects were reported like atrial fibrillation, atrioventricular block or torsade de pointe. Further studies are needed especially in the "real life" in order to precise the exact prevalence of such cardiovascular alterations. CONCLUSION: Without conclusive evidence, potential cardiovascular adverse effects of anticholinergic agents used in overactive bladder must lead to a cautious prescription.

[Antibiotic prophylaxis in urodynamics: Clinical practice guidelines using a formal consensus method]. / Antibioprophylaxie et bilan urodynamique : recommandations de bonne pratique par consensus formalisé.

OBJECTIVE: The aim of this work was to issue clinical practice guidelines on antibiotic prophylaxis in urodynamics (urodynamic studies, UDS). MATERIALS AND METHODS: Clinical practice guidelines were provided using a formal consensus method. Guidelines proposals were drew up by a multidisciplinary experts group (pilot group = steering group), then rated by a panel of 12 experts (rating group) using a formal consensus method, and then peer reviewed by a reviewing/reading group of experts (different from the rating group). RESULTS: Urine (bacterial) culture with antimicrobial susceptibility testing is recommended for all patients before UDS (strong agreement). In patients with no neurologic disease, the risk factors for tract urinary infection (UTI) after UDS are age > 70 years, recurrent UTI, and post-void residual volume > 100ml. In patients with neurologic disease, the risk factors for UTI after UDS are recurrent UTI, vesicoureteral reflux, and intermicturition pressure > 40cmH2O. If the urine culture is negative before UDS and there is no risk factor for UTI, antibiotic prophylaxis is not recommended (Strong agreement). If the urine culture is negative before UDS, but there are one or more risk factors for UTI, antibiotic prophylaxis is optional. If antibiotic prophylaxis is initiated, a single oral dose (3g) of fosfomycin-tromethamine two hours before UDS is recommended (Strong agreement). If there is bacterial colonization on UCB before UDS, antibiotic therapy is optional (Undecided). If prescribed, it should be adapted to the antimicrobial susceptibility of the identified bacterium or bacteria, started the day before and stopped after UDS (except for fosfomycin-tromethamine: a single dose the day before UDS is necessary and sufficient) (Strong agreement). In the event of UTI before UDS, the UTI should be treated and UDS postponed (Strong agreement). The proposed recommendations should not be changed for patients with a hip or knee replacement (Strong agreement). No antibiotic prophylaxis of bacterial endocarditis is necessary, including in high-risk patients with valvular heart disease (Strong agreement). CONCLUSION: These new guidelines should help to harmonize clinical practice and limit exposure to antibiotics. LEVEL OF EVIDENCE: 4.

[Pathophysiology of detrusor underactivity in the elderly]. / Physiopathologie de l'hypoactivité détrusorienne de la personne âgée.

AIM: The aim of this study was to review the evidence regarding the pathophysiology of detrusor underactivity in the elderly. METHODS: A literature review was conducted in July 2016 using the Medline/Pubmed database limiting the search to works in English or French. RESULTS: The prevalence of detrusor underactivity has been reported to range from 8% to 48% depending on the definition used and the age of the population studied. Current data suggest that aging may itself be a causative factor of detrusor underactivity through myogenic dysfunctions (ultrastructural degeneration of the detrusor muscle) and neurogenic dysfunctions (by degeneration of efferent but mostly afferent innervation mechanisms). Beyond these inherently age-related mechanisms, many comorbidities whose prevalence increase with age (diabetes, bladder outlet obstruction, estrogen deficiency, atherosclerosis, etc.) may be implicated in the development of detrusor underactivity in the elderly. The role played by detrusor overactivity in the appearance of detrusor underactivity must be considered separately as both seem to be the expression of the same condition of the lower urinary tract responding to different stages and secondary to numerous etiopathogenic factors which modulate its progression and clinical expressions. CONCLUSION: Pathophysiology of detrusor underactivity remains poorly understood but seems to imply myogenic and neurogenic factors which are favored, besides the aging per se, by various and numerous comorbidities which prevalence increase with age (diabetes, bladder outlet obstruction…).

[Does hysterectomy modifies the anatomical and functional outcomes of prolapse surgery?: Clinical Practice Guidelines]. / L'hystérectomie modifie-t-elle les résultats anatomiques et fonctionnels de la cure de prolapsus ? : Recommandations pour la pratique clinique.

OBJECTIVE: Provide guidelines for clinical practice concerning hysterectomy during surgical treatment of pelvic organ prolaps, with or without mesh. METHODS: Systematically review of the literature concerning anatomical and functionnal results of uterine conservation or hysterectomie during surgical treatment of pelvic organ prolaps. RESULTS: Sacrospinous hysteropexy is as effective as vaginal hysterectomy and repair in retrospective comparative studies and in a meta-analysis with reduced operating time, blood loss and recovery time (NP2). However, in a single RCT there was a higher recurrence rate associated with sacrospinous hysteropexy compared with vaginal hysterectomy. Sacrospinous hysteropexy with mesh augmentation of the anterior compartment was as effective as hysterectomy and mesh augmentation (NP2), with no significant difference in the rate of mesh exposure between the groups (NP3). Sacral hysteropexy is as effective as sacral colpopexy and hysterectomy in anatomical outcomes; however, the sacral colpopexy and hysterectomy were associated with increase operating time and blood loss (NP1). Performing hysterectomy at sacral colpopexy was associated with a higher risk of mesh exposure compared with sacral colpopexy without hysterectomy (NP3). There is no sufficient data in the literature to affirm that the uterine conservation improve sexual function (NP3). CONCLUSION: While uterine preservation is a viable option for the surgical management of uterine prolapse the evidence on safety and efficacy is currently lacking. © 2016 Published by Elsevier Masson SAS.

[Is the use of synthetic mesh by vaginal route decrease the risk of cystocele recurrence? Clinical practice guidelines]. / Une interposition prothétique synthétique inter-vésico-vaginale implantée par voie vaginale diminue-t-elle le risque de récidive de cystocèle ? Recommandations pour la pratique clinique.

INTRODUCTION: The use of prosthetic surgery by vaginal route has been widely used to try to reduce the risk of prolapse recurrence in the surgical treatment of vaginal cystoceles. Specific complications including type of erosion have led to randomized studies comparing surgery by vaginal route with and without use of Mesh. METHOD: This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systemactic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement (AP)). RESULTS: The use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1). However, there is no difference in the functional outcome and there is an increase in the number of reoperations related to specific complications, including vaginal erosions. CONCLUSION: If the use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1), no difference in functional outcome and the increased number of related reoperations specific complications including vaginal erosions, do not argue for the systematic use of mesh in the treatment of primary cystocele. It must be discussed case by case basis taking into account a risk-benefit uncertain at long-term (grade B). Its use should be supported by additional studies focused on specific populations at risk of recurrence. © 2016 Published by Elsevier Masson SAS.

[Prevalence and initial management of overactive bladder in France: A cross-sectional study]. / Prévalence et prise en charge initiale de l'hyperactivité vésicale en France : une étude transversale.

AIMS: To determine the prevalence of overactive bladder (OAB) syndrome in France and gather data about initial patient trajectories in the healthcare system. METHODS: A dedicated questionnaire (41 questions) has been sent to a 12,000 sample of people representative of the global population. The following data were investigated: social and demographic features, medical history, Urinary Symptom Profile questionnaire, bother, history of symptoms, care seeking and treatments received. Patient were considered having OAB in case if presenting at least two episodes of urgency per week, or being under treatment of OAB. OAB prevalence was the main outcome, and associated factors were characterized by univariate and multivariate analysis. RESULTS: Based on 8842 available questionnaires, the global prevalence of OAB was estimated to be 14.4%. Prevalence was significantly higher in women, older age groups, as well as obesity, irritable bowel syndrome, urinary tract infections, enuresia, constipation, anxiety/depression, neurological diseases, sleep apnea syndrome, asthma, chronic obstructive pulmonary disease, diabetes and hypertension. Only 34.6% of patients with OAB had visited a health practitioner for this problem. General practitioners were most frequently implicated in patient primary care and evaluation. Seventy-two percent of patients with OAB had had additional investigations (mostly a urine culture) and only 6% of patients had to complete a bladder diary. The most frequent treatment option was oral antimuscarinics. Physical therapy and rehabilitation have been prescribed in 26% of cases, as well as dietary advice. CONCLUSIONS: OAB is a frequent syndrome. Its prevalence increases with age, and OAB frequently concern elderly frail people with many other associated diseases. LEVEL OF EVIDENCE: 3.

[Impact of laparoscopic sacrocolpopexy, with or without a midurethral sling, on lower urinary tract symptoms]. / Impact de la promonto-fixation cœlioscopique, avec ou sans bandelette sous-urétrale, sur les symptômes du bas appareil urinaire.

OBJECTIVE: To evaluate the impact of laparoscopic sacrocolpopexy, with or without simultaneous midurethral sling (MUS), on urinary symptoms and health-related quality of life of patients. MATERIALS: A prospective analysis was carried out including 83 women with symptomatic pelvic organ prolapse who had laparoscopic sacrocolpopexy between 2009 and 2011. Patients were classified according to the preoperative clinical examination (stress test). Thirty patients with patent (group A) stress urinary incontinence (SUI) and 15 patients with occult SUI (group B) had a MUS associated with sacrocolpopexy. Thirty-eight patients with negative stress test (group C) were treated by sacrocolpopexy without MUS, even if they had history of SUI. At each visit, urinary symptoms (UDI-6) and their impact on quality of life (UIQ-7) were evaluated using validated self-questionnaires, Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. RESULTS: After 3years of mean follow-up, SUI was improved in 22/30 (77%) of patients in group A and only one patient needed a second MUS. Dysuria was cured in 9/12 (75%), 5/7 (71%) and 16/19 (84%) of patients of groups A, B, C respectively and urge urinary incontinence in 13/19 (68%), 2/2 (100%) and 4/6 (67%) of patients. The rate of de novo urge incontinence was respectively 1/11 (9%), 2/13 (15%) and 6/32 (19%). De novo SUI appeared in 6/32 (19%) of patients in group C, but only 2 of them secondarily needed a MUS. After 3 years, our study showed a significant decrease of UDI-6 of 62, 63 and 48% comparing with preoperative score and of UIQ-7 of 77, 54 and 81%. CONCLUSION: Laparoscopic sacrocolpopexy associated with MUS for patent stress urinary incontinence improves significantly stress and urgency urinary incontinence. Laparoscopic sacrocolpopexy without MUS, when physical exam shows a negative stress test, significantly reduces voiding difficulties with very few cases of de novo stress and urge incontinence. LEVEL OF EVIDENCE: 4.

[Assessment before surgical treatment for pelvic organ prolapse: Clinical practice guidelines]. / Bilan avant le traitement chirurgical d'un prolapsus génital : Recommandations pour la pratique clinique.

INTRODUCTION: The issue addressed in this chapter of recommendations is: What is the clinical and para-clinical assessment to achieve in women with genital prolapse and for whom surgical treatment has been decided. What are the clinical elements of the examination that must be taken into account as a risk factor of failure or relapse after surgery, in order to anticipate and evaluate possible surgical difficulties, and to move towards a preferred surgical technique? MATERIAL AND METHODS: This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane Database of Systemactic Reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement [AP]). RESULTS: It suits first of all to describe prolapse, by clinical examination, helped, if needed, by a supplement of imagery if clinical examination data are insufficient or in case of discrepancy between the functional signs and clinical anomalies found, or in case of doubt in associated pathology. It suits to look relapse risk factors (high grade prolapse) and postoperative complications risk factors (risk factors for prothetic exposure, surgical approach difficulties, pelvic pain syndrome with hypersensitivity) to inform the patient and guide the therapeutic choice. Urinary functional disorders associated with prolapse (urinary incontinence, overactive bladder, dysuria, urinary tract infection, upper urinary tract impact) will be search and evaluated by interview and clinical examination and by a flowmeter with measurement of the post voiding residue, a urinalysis, and renal-bladder ultrasound. In the presence of voiding disorders, it is appropriate to do their clinical and urodynamic evaluation. In the absence of any spontaneous or hidden urinary sign, there is so far no reason to recommend systematically urodynamic assessment. Anorectal symptoms associated with prolapse (irritable bowel syndrome, obstruction of defecation, fecal incontinence) should be search and evaluated. Before prolapse surgery, it is essential not to ignore gynecologic pathology. CONCLUSION: Before proposing a surgical cure of genital prolapse of women, it suits to achieve a clinical and paraclinical assessment to describe prolapse (anatomical structures involved, grade), to look for recurrence, difficulties approach and postoperative complications risk factors, and to appreciate the impact or the symptoms associated with prolapse (urinary, anorectal, gynecological, pelvic-perineal pain) to guide their evaluation and their treatment. © 2016 Published by Elsevier Masson SAS.

[French translation of "An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction" published in Int Urogynecol J 2010;21(1):5-26]. / Traduction française de la terminologie commune International Urogynecological Association (IUGA)/International Continence Society (ICS) sur les troubles de la statique pelvienne chez la femme initialement publiée dans Int Urogynecol J 2010;21(1):5-26.

INTRODUCTION AND HYPOTHESIS: Given its increasing complexity, the terminology for female pelvic floor disorders needs to be updated in addition to existing terminology of the lower urinary tract. To do this, it seems preferable to adopt a female-specific approach and build on a consensus based on clinical practice. METHODOLOGY: This paper summarizes the work of the standardization and terminology committees of two international scientific societies, namely the International Urogynecological Association (IUGA) and the International Continence Society (ICS). These committees were assisted by many external expert referees. A ranking into relevant major clinical categories and sub-categories was developed in order to allocate an alphanumeric code to each definition. An extensive process of 15 internal and external reviews was set up to study each definition in detail, with decisions taken collectively (consensus). RESULTS: Terminology was developed for female pelvic floor disorders, bringing together more than 250 definitions. It is clinically based and the six most common diagnoses are defined. The emphasis was placed on clarity and user-friendliness to make this terminology accessible to practitioners and trainees in all the specialties involved in female pelvic floor disorders. Imaging investigations (ultrasound, radiology, MRI) exclusively for women have been added to the text, relevant figures have also been included to complete the text and help clarify the meaning. Regular reviews are planned and are also required to keep the document up-to-date and as widely acceptable as possible. CONCLUSIONS: The work conducted led to the development of a consensual terminology of female pelvic floor disorders. This document has been designed to provide substantial assistance in clinical practice and research. LEVEL OF EVIDENCE: 4.

[Clinical practice guidelines: Summary of recommendations for first surgical treatment of female pelvic organ prolapse by 5 French academic societies: AFU, CNGOF, SIFUD-PP, SNFCP, and SCGP]. / Recommandations pour la pratique clinique : Synthèse des recommandations pour le traitement chirurgical du prolapsus génital non récidivé de la femme par l´AFU, le CNGOF, la SIFUD-PP, la SNFCP et la SCGP.

OBJECTIVE: Providing clinical practice guidelines for first surgical treatment of female pelvic organ prolapse. METHODS: Systematic literature review, level of evidence rating, external proofreading, and grading of recommendations by 5 French academic societies: Association française d'urologie, Collège national des gynécologues et obstétriciens français, Société interdisciplinaire d'urodynamique et de pelvi-périnéologie, Société nationale française de coloproctologie, and Société de chirurgie gynécologique et pelvienne. RESULTS: It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (Grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (Grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (Grade B). A bowel preparation before vaginal (Grade B) or abdominal surgery (Grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (Grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (Grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (Grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (Grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (Grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (Grade C). Clinical practice guidelines. © 2016 Published by Elsevier Masson SAS.

[Evaluation of urine postvoid residuals in post-partum period: a prospective and descriptive clinical study]. / Évaluation des résidus postmictionnels du postpartum: étude prospective descriptive.

INTRODUCTION: Few studies have evaluated urine postvoid residuals (PVRs) and their risk factors during the post-partum (PP) period. The aim of this prospective study was to screen postvoid residuals in a cohort of patients in PP, and to identify the risk factors. MATERIALS AND METHODS: For three months, patients in PP were given an evaluation of their PVR (ultrasounds method) after a spontaneous urination. Clinical data as regards delivery were collected. RESULTS: One hundred and sixty-eight patients were included. Among them, 61% had a urine volume at the first urination over 500 mL, and 52% presented with a pathological PVR (PVR over 150 mL for a urine volume over 150 mL). The median PVR was 153.50 mL. The median volume of the first spontaneous urination was 400 mL. Among patients with a pathological PVR, the total duration of the labor and the duration of its second phase were significantly longer (P=0.003 and P<0.05, respectively), and the volume of the first urination was higher. Indwelling catheterization during the delivery decreased the volume of the first spontaneous urination (volume over 500 mL in 28% vs 72% of patients, P=0.017) but was not associated with a decreased PVR in non-pathological deliveries. Instrumental deliveries were associated with higher PVRs than caesarean or physiological deliveries (244 mL, 180 mL et 156 mL; P=0.033). A bacteriuria was not significantly associated with PVR (54% vs 49%, P>0.05). CONCLUSION: We were able to identify risk factors for PVR in the PP, such as the duration of labor, instrumental delivery and elevated volume of the first urination after delivery.

[Idiopathic overactive bladder and BOTOX(®): Literature review]. / Hyperactivité vésicale idiopathique et BOTOX(®): revue de la littérature.

AIM: Systematically review literature on the efficacy and tolerability of botulinum toxin A (onabotulinumtoxineA, BOTOX(®), Allergan, CA, USA) in refractory idiopathic overactive bladder (iOAB) METHODS: Pubmed search on the efficacy, toxicity and adverse events of onabotulinumtoxinA in clinical trials only with level 1 and 2 evidence. RESULTS: Eleven controlled randomised trials have been selected, of which 3 phase III trials. The studies published data of 1008 patients with refractory iOAB treated with onabotulinumtoxineA. In the phase II and III trials, doses from 50 U to 300 U have been evaluated; more than half of the patients (n = 676) with 100 U. In the 2 main phase III trials, onabotulinumtoxinA has demonstrated to be more efficient compared to placebo on continence, symptoms and quality of live (QoL). Urodynamic results, reported in the phase II trials, demonstrated higher changes compared to placebo only from dose 100 U on, although not always significant. Adverse events (urinary retention, dysuria, urinary tract infection) were easily treated and did not influence patient's QoL. CONCLUSION: Intradetrusor injections of onabotulinumtoxinA (BOTOX(®)), a minimally-invasive procedure, seem to be efficient and well tolerated in the treatment of refractory iOAB.

[Functional symptoms and associations of women with genital prolapse]. / Prévalence des troubles fonctionnels et associations anatomo-fonctionnelles chez les femmes présentant un prolapsus génital.

OBJECTIVE: To assess functional symptoms related to genital prolapse and to test anatomo-functional associations. PATIENTS AND METHODS: Observational study, performed between January 2005 and June 2012, on all patients operated for prolapse in a French tertiary referral centre. Data were collected from standardized patients' notes, including baseline characteristics, complete interview on urinary and colo-rectal functional symptoms, MHU score, and POP-Q (Pelvic Organ Prolapse Quantification) clinical evaluation. RESULTS: Three hundred and seventy-four patients, with a mean age of 65.1 years old, mean parity of 2.5, and mean BMI of 25.4, were included. These patients were post-menopausal in 92.5% of cases. Urinary symptoms were: SUI in 30.5%, urgencies in 44.4%, and voiding difficulties in 38.8%. Colo-rectal symptoms, such as defecatory dysfunction and anal incontinence, occurred in 25.1% and 18.5%, respectively. On clinical examination, anterior vaginal wall prolapses were the most common (74.1%). Patients with stage 3-4 cystocele suffered significantly more frequently of nocturia (P=0.04), voiding difficulties (P=0.04), and occult stress urinary incontinence (P<0.001). Patients with stage 3-4 rectocele suffered significantly more frequently of defecatory dysfunction (P=0.005) and performed more often maneuver for defecation (P<0.001). CONCLUSION: Urinary and colo-rectal symptoms are commonly associated with genital prolapse. Anatomo-functional associations were shown regarding different prolapse types and stages. LEVEL OF PROOF: 4.

[Guidelines concerning urinary incontinence in elderly: construction and validation of GRAPPPA algorithm]. / Recommandations concernant l'incontinence urinaire de la personne âgée : construction et validation de l'algorithme décisionnel GRAPPPA.

OBJECTIVES: Provide guidelines presented as an algorithm for practical evaluation and first line therapy of urinary incontinence in elderly. PATIENTS AND METHODS: Guidelines using formalized consensus guidelines method. These guidelines have been validated by a group of 40 experts quoting proposals, subsequently reviewed by an independent group of multidisciplinary experts (urologist, general practitioner, neurologist, gynecologist, geriatrist, specialist in physical medicine and rehabilitation). RESULTS: By means of 3 rounds of interrogation of the expert panel, GRAPPPA algorithm was constructed. This algorithm take in account both evaluation and first line therapeutic options in the different type of incontinences observed in this population (urge, stress and mixed incontinence). Initial evaluation consists to track down urinary retention (and subsequently fecal stool impaction, use of anticholinergic or morphinic drugs), urinary tract infection and cognitive impairment. Haematuria, bladder-pelvic pain, history of radiotherapy or recent pelvic surgery, lead to refer the patient to a specialized unit. First line therapy is in all the cases pelvic floor training, use of local oestrogenotherapy and dietetic measures. In urge incontinence, anticholinergic drugs may be used. CONCLUSIONS: Implementation of this algorithm may promote best practice in management of urinary incontinence in elderly.

[Impact on cognitive function of anticholinergic drugs used for the treatment of overactive bladder in the elderly]. / Traitement anticholinergique de l'hyperactivité vésicale de la personne âgée et ses impacts sur la cognition. Revue de la littérature.

OBJECTIVES: Describe the central nervous system (CNS) adverse effects of anticholinergic drugs used for the treatment of overactive bladder (OAB) in the elderly. PATIENTS AND METHODS: Relevant data from the literature were identified primarily through a Medline search of articles published through December 2013. The search terms included overactive bladder, central nervous system, elderly, anticholinergic, and antimuscarinic. Articles were chosen for inclusion based on their pertinence to the focus on treatment of OAB in the elderly. RESULTS: Several anticholinergic drugs are available for the treatment of OAB, including oxybutinin, tolterodine, trospium chloride, solifenacine, fesoterodine. Among the agents reviewed, penetration of the blood-brain barrier (as predicted by lipophilicity, polarity, and molecular size and structure) is highest for oxybutinin, lower for tolterodine, solifenacine, and darifenacine, and lowest for fesoterodine and trospium chloride. Unwanted CNS adverse effects depend in part on patient specific variability in pharmacokinetic parameters, blood-brain barrier permeability, degree of cholinergic neuronal degeneration, total anticholinergic drug burden and patient's baseline cognitive status. The spectrum of anticholinergic CNS adverse effects ranges from drowsiness to hallucinations, severe cognitive impairment, and coma. Among the different anticholinergic agents, oxybutinin has been associated with cognitive impairment and trospium chloride and fesoterodine have shown favorable CNS tolerability. CONCLUSIONS: Anticholinergic drugs improve significatively overactive bladder symptoms in older adults. However, potential CNS adverse effects of anticholinergic agents used in OAB must lead to a full evaluation before and during the treatment in order to evaluate benefice, risks and central side effects in this frail population.