Midterm postoperative results of mid-urethral slings. Role of ultrasound in explaining surgical failures.

INTRODUCTION: Surgical treatment for stress urinary incontinence (SUI) with mid-urethral sling (MUS) is considered to have a high success rate. However, between 5% and 20% of MUS fail, with inadequate surgical implantation being a possible cause of SUI persistence or recurrence. Misplacement of a MUS can be determined by pelvic floor ultrasound (PF-US). The aim of this study was to investigate the role of PF-US in patients with persistent or recurrent urinary incontinence (UI) symptoms after MUS surgery for SUI with a midterm follow-up. MATERIALS AND METHODS: A historical cohort study including women undergoing MUS surgery for SUI between 2013 and 2015 was designed. The primary outcome was to correlate the sonographic parameters of MUS with SUI cure (negative International Continence Society-Uniform Cough Stress Test, Incontinence Questionnaire-Short Form < 5 points and no symptoms of SUI), at 5 years postsurgery. Secondary outcomes were changes of maximum urethral closure pressure (MUCP) and symptoms of urgency urinary incontinence (UUI) at 1 and 5 years after surgery. RESULTS: Eighty-seven patients (80 transobturator-MUS, 7 retropubic-MUS) were included. At 5 years all patients referred improvement of UI and objective cure of SUI was demonstrated in 81.2%. The MUS was sonographically correct in 67 (98.5%) of the 68 patients with cure of SUI. The MUS was considered incorrectly placed in only 4 (28.6%) of the 14 patients with noncured SUI. MUCP decreased from 61.9 to 48.8 cmH2 O at 5 years of follow-up (p < 0.01) and up to 53% of women had UUI symptoms after surgery, with a nonsignificant decrease compared to baseline. CONCLUSION: Patients cured of SUI had sonographically correct MUS by PF-US. Less than one-third of cases of SUI persistence or recurrence after MUS surgery could be explained by a sonographically incorrect sling. Low urethral resistance and/or UUI symptoms could help to explain the remaining failures. Complete functional and anatomic studies, including urodynamics and PF-US, should be performed before deciding on the next management strategy in patients with SUI persistence or recurrence after MUS.

Female sexuality before and after sacrocolpopexy or vaginal mesh: is vaginal length one of the key factors?

INTRODUCTION AND HYPOTHESIS: We aimed to demonstrate that laparoscopic sacrocolpopexy/cervicopexy (LSC-Cx) versus anterior vaginal mesh (AVM) results in a longer vaginal length without impacting sexual activity or function. METHODS: We performed a secondary analysis of sexual outcomes of a previous randomized control trial comparing LSC-Cx and AVM in 120 women (60/group) with symptomatic POP stage ≥ 3. We evaluated sexually active (SA) and non-sexually active women (NSA) using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-IUGA-Revised (PISQ-IR) preoperatively and 1 year postoperatively. Multivariate logistic and linear regression models were built to assess the impact of different variables on sexual activity and function, respectively. RESULTS: Among 120 women included, no statistically significant differences were found between vaginal length and preoperative dyspareunia (20.7% AVM vs. 22,8% LSC-Cx) comparing SA to NSA women and LSC-Cx to AVM. Vaginal length was significantly longer after LSC-Cx versus AVM (p < 0.001). The postoperative dyspareunia rate was 17.2% AVM versus 10.5% LSC-Cx. Partnered women were significantly more likely to be SA than unpartnered women before (OR = 19.04; p = 0.006) and after surgery (OR = 36.28; p = 0.002). Only dyspareunia was independently associated with sexual function pre- (B = -0.431; p = 0.017) and postoperatively (B = -0.3 96; p = 0.007). CONCLUSIONS: Vaginal length was greater following LSC-Cx compared to AVM. While vaginal length has no impact on female sexuality pre- and postoperatively, the most important factors were "having a partner" for sexual activity and dyspareunia for sexual function. Persistence of dyspareunia was higher after AVM. LSC-Cx should be considered in women with POP undergoing mesh surgery with future sexual expectations.

Mid-term results of the Remeex® readjustable sling for female complex stress urinary incontinence and sonographic hypomobile urethra.

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate the results of a readjustable sling (Remeex® system) among a selected group of women with complex stress urinary incontinence (SUI) with sonographic hypomobile urethra and assessing failure-related risk factors. METHODS: Observational, longitudinal, prospective cohort study, including patients who underwent surgery with the Remeex® system. The primary outcome was a binary outcome in change of one level or more of the severity of urinary incontinence symptoms according to the intervals of the Incontinence Questionnaire-Short Form (ICIQ-UI-SF) score (mild, moderate, severe and very severe). Secondary outcomes were postsurgical complications, absolute ICIQ-UI-SF, 24-h pad weight test (24-h PT), urodynamic SUI and Patient Global Impression of Improvement (PGI-I) score to evaluate subjective success. RESULTS: Among 120 women included, after surgery we found a 70% subjective success rate, a 76.7% decrease of urinary incontinence severity and a mean reduction of the 24-h PT of 109.6 ± 291.4 g. Women with post-surgical decreased severity of incontinence had lower mean body mass index (BMI) and 24-h PT than those without incontinence severity changes with statistically significant differences (p = 0.028 and p = 0.027, respectively). A logistic regression model demonstrated that a 1-point increase of BMI increased the risk of persistence of incontinence severity after surgery by 19% (OR = 1.19; 95% CI: 1.01-1.41; p = 0.040), and an increase of 10 g in the pre-surgical 24-h PT represented a 3% rise of the aforementioned risk (OR = 1.03; 95% CI: 1.01-1.06; p = 0.034). CONCLUSIONS: In patients with complex SUI and sonographic hypomobile urethra, use of a readjustable sling (Remeex® system) led to improvement of SUI. Patients with a greater BMI and pre-surgical 24-h PT showed worse results after surgery.

Readjustable Sling in Women With Stress Urinary Incontinence and Hypomobile Urethra: Understanding the Mechanisms of Closure by Transperineal Ultrasound.

OBJECTIVES: To assess the postsurgical sonographic parameters of a readjustable sling (RAS) according to urinary incontinence (UI) symptoms after surgery and compare this RAS sonographic pattern with mid-urethral slings (MUS). METHODS: Observational, prospective multicenter study, including women undergoing stress urinary incontinence (SUI) surgery with RAS (Remeex®). The primary outcome was the association between UI symptoms and sonographic parameters measured by two-dimensional transperineal and high-frequency endovaginal ultrasound. We measured static parameters (bladder neck funneling, RAS position, symmetry, distance to the urethral lumen), and the movement of the sling on Valsalva. UI symptoms were measured with the postsurgical Incontinence Questionnaire-Short Form (ICIQ-UI-SF) questionnaire. We created two control groups including patients with transobturator-MUS (TOT-MUS) and retropubic-MUS (RT-MUS) to compare postsurgical sonographic parameters of RAS with MUS. RESULTS: Among the 55 women with RAS included, the postoperative ICIQ-UI-SF scores were significantly higher in patients with bladder neck funneling (15.0 (3.9) vs 10.6 (6.7); P = .020) and in those with discordant movement of RAS on Valsalva (14.6 (5.7) vs 10.3 (6.7); P = .045). Compared with the 109 women with TOT-MUS and the 55 with RT-MUS, RAS was more often located in the proximal urethra and farther from the urethral lumen. CONCLUSIONS: Postsurgical pelvic floor ultrasound demonstrated that in women with complex SUI and hypomobile urethra who underwent RAS (Remeex®) surgery, the presence of bladder neck funneling and discordant movement on Valsalva correlate with the persistence of UI symptoms. In these women, RAS is more often located in the proximal urethra and farther from the urethral lumen at rest in comparison with MUS.

Sexual activity and function in women with advanced stages of pelvic organ prolapse, before and after laparoscopic or vaginal mesh surgery.

INTRODUCTION AND HYPOTHESIS: The differential impact of specific pelvic organ prolapse (POP) surgery on sexual activity and function is unknown. Our primary aim was to analyse sexual inactivity and function in women with symptomatic advanced stages of POP and the changes incurred after laparoscopic or vaginal mesh surgery. METHODS: We performed a secondary analysis of sexual outcomes of a previously published randomised controlled trial comparing laparoscopic sacrocolpopexy/cervicopexy (LSC-Cx) and anterior vaginal mesh (AVM) in 120 women (60/group) with symptomatic anterior POP stage ≥ 3 and apical ≥ 2. Sexual activity and function were assessed preoperatively and 1 and 2 years postoperatively using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-IUGA-Revised (PISQ-IR). RESULTS: Sexual activity was recovered in 42.9% of non-sexually active (NSA) women 1 year postoperatively, mainly in women with higher preoperative POP-related subscale scores of the PISQ-IR, which indicated a negative preoperative sexuality by POP. Recovery of sexual activity was greater after LSC-Cx, albeit not significantly (2 years: 35.5% AVM vs. 45% LSC-Cx). Among sexually active (SA) women preoperatively remaining SA postoperatively, the difference in the mean PISQ-IR summary score significantly improved [mean baseline difference - 2 years; all: 0.3 (95% CI 0.1 to 0.5) p = 0.001; AVM 0.19 (95% CI -0.1 to -0.5) p > 0.05; LSC-Cx 0.37 (95% CI 0.1 to 0.7) p = 0.003]. Preoperative dyspareunia was significantly reduced after LSC-Cx (baseline: 24.6%, 2 years: 9.8%, p = 0.0448), but not after AVM (baseline: 20.7%, 2 years: 18.2%, p = 0.7385). CONCLUSIONS: Most women reported improved sexual activity and function 2 years after LSC-Cx or AVM, mainly because of enhanced POP-related subscales in both NSA and SA women. Recovery of sexual activity and improved sexual function were greater after LSC-Cx compared to AVM, likely related to less postoperative dyspareunia.

Cough stress tests to diagnose stress urinary incontinence in women with pelvic organ prolapse with indication for surgical treatment.

AIMS: To evaluate the diagnostic ability of different cough stress tests (CSTs) in women with pelvic organ prolapse (POP), performed during outpatient urogynaecological exams. METHODS: Prospective, multicentre observational study involving women on waiting lists for POP surgery. With a subjectively full bladder, patients were asked to perform five different CSTs: without prolapse reduction ([a] standing, followed by [b] semilithotomy position); keeping semilithotomy position with prolapse reduced (by [c] posterior speculum, followed by [d] pessary); [e] standing again with the pessary in place. Primary outcome was positive CST in at least one of the five CSTs. Bladder volume was measured and symptoms of stress urinary incontinence (SUI) were detected by two validated questionnaires. RESULTS: A total of 297 women completed all CSTs and were included in the analyses. Mean (SD) age, parity, and body mass index were 64.8 (9.9) years, 2.7 (1.3) deliveries, and 26.6 (3.4) kg/m2 , respectively. In total, 99 women (33.3%) reported SUI symptoms. At least one positive CST was recorded in 152 patients (51.1%), and in 90 (59.2%) of these 152, a positive CST was observed only when POP was reduced (occult SUI). The CST was positive in 92 (92.9%) of the 99 patients with coexisting SUI symptoms and in 60 (30.3%) of the 205 asymptomatic patients. The percentage of patients with a positive CST was significantly lower when bladder volume was <200 mL vs ≥200 mL (P = .046). CONCLUSIONS: The identification of urinary leakage cases with CSTs is best achieved using multiple different patient positions, different prolapse reduction methods, and bladder volumes ≥200 mL.

Position of Ibero-American Society of Neurourology and UroGynecology (SINUG) on the use of vaginal meshes in pelvic organ prolapse.

AIMS: Pelvic organ prolapse (POP) is a very prevalent condition with a great impact on women's quality of life. At present, there is great controversy regarding the use of mesh in POP surgery. To understand the current moment, it is advisable to make a brief summary of the historical evolution of mesh use for pelvic floor pathology. The aim of this paper is to establish the position of the Ibero-American Society of Neurourology and UroGynecology (SINUG for its acronym in Spanish) regarding vaginal mesh reconstructive surgery. METHODS: A working committee from the SINUG's scientific board performed a literature search about the use of vaginal meshes for pelvic organ prolapse reconstructive surgery and about the position of different societies. We analyzed the evolution into three periods: before the Food and Drug Administration (FDA) statement, FDA statement, and after the statement. SINUG drew up a position statement regarding vaginal mesh reconstructive surgery, based on the available scientific evidence and the evolution of its use in different contexts. RESULTS: Before mesh appearance in the 1990s, native tissue repair was the surgical treatment of choice for POP. Vaginal mesh reconstructive surgery has been frequently accompanied by procedure underestimation by inexperienced surgeons, besides inadequate diagnoses and indications. This situation led to the presentation of serious complications including mesh extrusion, exposure, and contraction. CONCLUSIONS: Once reviewed the available evidence and the position of different societies, SINUG presents its vision in this communication, which is a summary of the document prepared by the society's scientific board.

Position of the Ibero-American Society of Neurourology and Urogynecology in relation to the use of synthetic suburethral meshes for the surgical treatment of female stress incontinence.

AIMS: The aim of this paper is to stablish de position of the Ibero-American Society of Neurourology and Urogynecology (SINUG) in relation to the use of suburethral meshes for the surgical treatment of female stress incontinence. METHODS: Tension-free mid-urethral slings (MUS) have become the most popular procedure for the treatment of stress urinary incontinence (SUI). In July 2018, the British government announced a pause in the use of meshes for both pelvic organ prolapse (POP) and urinary incontinence (UI) treatment without differentiating whether the meshes were used for treating UI or POP. The decision was taken to stop their use until the publication of the updated UI and POP guidelines of the British National Health Service, which is available from April 2019. SINUG has reviewed the evidence and official position of different societies in relation to the safety and efficacy of MUS in the surgical treatment of incontinence differentiating them from meshes used to repair POP. RESULTS: Data from synthetic mesh manufacturers indicate that in 2010, 300 000 women underwent surgical procedures to repair POP and approximately 260 000 were operated on for SUI. According to these estimates, approximately more than 80% of the surgical techniques for UI treatment were performed transvaginally with meshes. CONCLUSIONS: Once reviewed evidence and position of different societies, the SINUG presents its vision in this communication, which is a summary of the document analysing the state of topic prepared by the society.

Anatomical outcomes 1 year after pelvic organ prolapse surgery in patients with and without a uterus at a high risk of recurrence: a randomised controlled trial comparing laparoscopic sacrocolpopexy/cervicopexy and anterior vaginal mesh.

INTRODUCTION AND HYPOTHESIS: Few studies have compared the different approaches of mesh surgery in patients with severe pelvic organ prolapse (POP). In addition to laparoscopic sacrocolpopexy/cervicopexy (LSC-Cx), anterior vaginal mesh (AVM) may be an effective approach for correcting anterior vaginal wall associated with apical POP in women with advanced POP. METHODS: A randomised controlled trial (RCT; January 2011 to March 2016) including 120 patients (60/group) with advanced symptomatic POP, with a predominant anterior vaginal wall descent stage III or greater in combination with a stage II or III apical defect (uterus or vaginal vault). Patients underwent four visits: baseline, 3, 6 and12 months after surgery. The main outcome was anatomical success defined as anterior and posterior vaginal wall not descending beyond the hymen and vaginal apex descent no more than one third into the vagina. Secondary variables: PFDI, ICIQ-UI-SF, intraoperative variables, postoperative morbidity and complications. RESULTS: Anatomical success was achieved with LSC-Cx in 79% and with AVM in 76% (NS). No statistically significant differences were found among POP-Q anterior vaginal wall points between groups, whereas better results were obtained with LSC-Cx in posterior vaginal wall points and total vaginal length. Intraoperative outcomes were similar in the two groups, except for operating time (78.05 min LSC-Cx vs 44.28 min AVM). There were no statistically significant differences related to de novo stress urinary incontinence and dyspareunia. Worse results were found in the CRADI-8 in the LSC-Cx group, owing to constipation. Late postoperative complications and reinterventions were similar in the two groups. CONCLUSIONS: No differences were found in the anatomical correction of anterior and apical POP. The LSC-Cx group presented better correction of posterior vaginal wall defects and a longer total vaginal length.

Coital resumption after delivery among OASIS patients: differences between instrumental and spontaneous delivery.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) are associated with sexual dysfunction and a lower likelihood of sexual activity in the postpartum period. The aim of the present study was to compare coital resumption and the variables influencing this activity after delivery in women with and without a history of obstetric anal sphincter injury (OASIS) and according to the mode of delivery. METHODS: A prospective, observational, case-control study was performed at 6 months postpartum in 318 women: 140 with a history of primary repaired OASIS and 178 women without OASIS. Demographic and obstetric data, breastfeeding, and symptoms of urinary and anal incontinence were collected. Patients were asked about coital resumption and completed the validated specific Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12). Continuous and non-continuous variables were compared using ANOVA and the Fisher exact tests, respectively. A multivariate logistic regression model and a multiple regression analysis were constructed to assess the impact of demographic and clinical variables on the percentage of coital resumption and on the PISQ-12 score, respectively. RESULTS: After a spontaneous delivery (SD), patients without OASIS showed a higher percentage of coital resumption than those with OASIS (98% vs. 77%; p = 0.003), and the PISQ-12 score was also higher (p < 0.001). PISQ-12 score was better in women with SD compared to those with operative vaginal delivery (OVD)(p < 0.001), independently of the history of OASIS. Current breastfeeding, a higher Wexner score and OVD negatively influenced the PISQ-12 score. CONCLUSIONS: After SD, women with OASIS resumed coital activity later than women without OASIS. Women with OVD resumed coital activity later, and had a lower PISQ-12 score than women with SD.

Anatomic and functional evaluation of the levator ani muscle after an obstetric anal sphincter injury.

PURPOSE: To study the relationship between symptoms of anal incontinence (AI) and the anatomy and functionality of the levator ani muscle in women with a history of obstetric anal sphincter injury (OASI). METHODS: This is a cohort study including patients with OASI from 2013 to 2016. Patients were assessed by a physical examination, endoanal ultrasound using Starck Scale, perineometry and 4D transperineal ultrasound. AI in all patients was measured with the Wexner scale. Correlation between variables has been analyzed in these patients. RESULTS: 72 patients were analyzed: 28 with a IIIA degree tear, 26 with a IIIB, 13 with a IIIC and 5 with a IV. 38 patients showed a residual anal sphincter (AS) defect on endoanal ultrasound with an average Starck score of 6.5 ± 3.7. 21 patients expressed AI, with an average Wexner score of 4.1 ± 2.4. In 27 (37.5%) patients, a levator ani avulsion was observed: 17 unilateral and 10 bilateral. Patients with a levator ani defect had weaker pelvic floor muscle (PFM) function. These differences were statistically significant with perineometry (p = 0.01 and p = 0.03) but not for the Oxford test (p = 0.08). Patients with a residual AS defect as well as an injury to the levator ani muscle expressed greater AI symptomatology than patients with residual sphincter injury who maintain the integrity of the levator ani: Wexner 4.9 0.9 vs 3.3 1 (p = 0.02). CONCLUSIONS: The PFM has correlation with AI symptom development in patients with a history of OASI. Therefore, we suggest a key role of anatomical and functional assessments of the levator ani muscle in these patients.

ICS Educational Module: Cough stress test in the evaluation of female urinary incontinence: Introducing the ICS-Uniform Cough Stress Test.

INTRODUCTION: A cough stress test (CST) is recommended in the evaluation of the uncomplicated female patient with the complaint of stress urinary incontinence (SUI) to identify the sign of SUI, and is often used as an outcome measure following SUI treatment. However, there has been no standardization of the performance or reporting of CST. A working group of the International Continence Society (ICS) has developed an educational module, comprising a Powerpoint™ presentation and evidence base manuscript, to instruct on the performance, interpretation, and reporting of the CST in a standardized manner: the ICS-Uniform Cough Stress Test (ICS-UCST). METHODS: The working group performed a PUBMED literature search of articles (observational/experimental and reviews) published prior to 2017 that mentioned a CST. The evidence base examined various variables in performing a CST as well as sensitivity/specificity and positive/negative predictive values of CST. RESULTS: The variables involved in performing/interpreting an ICS-UCST include: patient positioning, degree of bladder filling, number, and forcefulness of coughs, and method of SUI detection. For the ICS-UCST it is recommended that the patient be in a supine/lithotomy position with 200-400 mL of fluid in the bladder. She coughs forcefully 1-4 times and the examiner directly visualizes the urethral meatus for the presence of leakage. Leakage of fluid from the urethral meatus coincident with/simultaneous to the cough(s) is considered a positive test. CONCLUSION: This module provides instructions to educate a uniform CST (the ICS-UCST), with the aim of improving the clinical practice of cough stress testing in female patients with urinary incontinence.

Prevalence, incidence, and remission rates of urinary incontinence in women attended in gynecological practice.

AIMS: To assess the prevalence of urinary incontinence (UI) in a cohort of women attended in primary care gynecological and estimate the incidence and remission rates of UI symptoms at 1 year. METHODS: We performed a multicenter prospective cohort study of women attending eight primary care gynecological practices. Consecutive women attended for gynecological issues different from UI were invited to participate in the study by answering the International Consultation on Incontinence questionnaire-Short Form (ICIQ-UI-SF). Patients receiving treatment for UI, during pregnant, and postpartum were excluded. All women with UI symptoms (ICIQ-UI-SF > 0) wishing treatment were studied and treated following routine clinical practice. All women were invited to answer the same questionnaire by phone 1 year after inclusion. RESULTS: A total of 2,840 women answered the questionnaire; 1,188 (41.8%) had UI symptoms (ICIQ-UI-SF > 0). Accordingly, nearly half (44.9%) had mild UI symptoms. Treatment was requested by only 551/1,188 incontinent women (46.38%), being related to the severity of UI. At 1 year, 2,443 patients/2,840 (86.0%) were found and again responded to the ICIQ-UI-SF. At 1 year the incidence of UI was 5.3% (77 new cases of UI out of 1,652 with the initial ICIQ-UI-SF = 0) while the remission rate of UI among untreated women was 27.9% (144 with ICIQ-UI-SF = 0). CONCLUSIONS: Almost one half of women attended in primary care general gynecology practices have UI symptoms, with less than 50% requesting treatment. In these women, UI is a dynamic process with an incidence of 5.3% and a remission rate of 27.9% at 1 year. Neurourol. Urodynam. 36:1081-1085, 2017. © 2016 Wiley Periodicals, Inc.

Spanish version of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA-Revised (PISQ-IR): Transcultural validation.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to transculturally adapt the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire IUGA-Revised (PISQ-IR) into Spanish and to validate the new version. METHODS: We carried out a two-stage observational cross-sectional study: translation and back-translation, followed by a validation stage in which the final version was administered to 268 consecutive women (118 not sexually active [NSA] and 150 sexually active [SA]) older than 18 from an Urogynecology Unit. Besides PISQ-IR, women also completed the following questionnaires: Incontinence Severity Index (ISI); Female Sexual Function Index (FSFI); Pelvic Floor Distress Inventory (PFDI-20); and question #35 from the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ). Feasibility (percentage of valid cases), internal consistency (Cronbach's alpha), and construct validity (structural, by factor analysis, and convergent validity by Spearman's Rho) were evaluated. RESULTS: The sample was formed by 118 NSA and 150 SA women, with a mean age (SD) of 59.2 (11.5) years; mean body mass index (BMI) of 29.6 kg/m2 (5.6), and mean parity of 2.6 deliveries (1.2). PISQ-IR showed a high response rate (98.3% NSA and 94.7% SA), and elevated internal consistency (Cronbach's alpha for NSA and SA of 0.79 and 0.91 respectively). Factor analysis confirmed the structure of the original questionnaire and the convergent validity showed moderate to strong correlation between PISQ-IR and the ISI, PFDI-20, and FSFI scores, in addition to item #35 of the EPIQ. CONCLUSIONS: The Spanish version of the PISQ-IR has adequate psychometric properties; therefore, it can be a useful tool for assessing sexual function in women with pelvic floor disorders.

Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms.

INTRODUCTION AND HYPOTHESIS: The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS). METHODS: From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan's classification. Participants were assessed at 6 months postpartum. Incontinence symptoms were evaluated using Wexner's score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck's system. Correlation between Sultan's and Starck's classifications was calculated using Cohen's kappa and Spearman's rho (Rs) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model. RESULTS: A total of 95 women were included in the study. Good correlation (κ= 0.72) was found between Sultan's and Starck's classifications. Significant positive correlation was observed between Wexner's score and both Sultan's (p = 0.023, Rs =0.212) and Starck's (p < 0.001, Rs =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner's score. CONCLUSIONS: The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.

Is electromyography a predictive test of patient response to biofeedback in the treatment of fecal incontinence?

AIM: Biofeedback is effective in more than 70% of patients with fecal incontinence. However, reliable predictors of successful treatment have not been identified. The aim was to identify clinical variables and diagnostic tests, particularly electromyography, that could predict a successful outcome. METHODS: We included 135 consecutive women with fecal incontinence treated with biofeedback. Clinical evaluation, manometry, ultrasonography, electromyography, and pudendal nerve terminal motor latency were performed before therapy. Treatment outcome was assessed using a symptoms diary, Wexner incontinence score and the patient's subjective perception. RESULTS: According to the symptoms diaries, 106 (78.5%) women had a good clinical result and 29 (21.5%) had a poor result. There were no differences in age, severity and type of fecal incontinence. Maximum resting pressure (39.3 ± 19.1 mmHg vs. 33.7 ± 20.2 mmHg; P = 0.156) and maximum squeeze pressure (91.8 ± 33.2 mmHg vs. 79.8 ± 31.2 mmHg; P = 0.127) were higher in patients having good clinical outcome although the difference was not significant. There were no differences in the presence of sphincter defects or abnormalities in electromyographic recordings. Logistic regression analysis found no independent predictive factor for good clinical outcome. CONCLUSIONS: Biofeedback is effective in more than 75% of patients with fecal incontinence. Clinical characteristics of patients and results of baseline tests have no predictive value of response to therapy. Specifically, we found no association between severity of electromyographic deficit and clinical response.

Bladder function after radical hysterectomy for cervical cancer.

AIM: To report the effects of radical hysterectomy and nerve-sparing techniques on lower urinary tract function in women. METHODS: A literature search was performed in Pubmed and Medline using the keywords bladder after radical hysterectomy, nerve sparing radical hysterectomy, and urinary dysfunction following radical hysterectomy. Significant results and citations were reviewed manually by the authors. RESULTS: The sympathetic and parasympathetic systems innervating the lower urinary tract may be disrupted due to resection of uterosacral and rectovaginal ligaments, the dorsal and lateral paracervix, the caudal part of the vesico-uterine ligaments, and the vagina. This supports the neurogenic etiology of early and late bladder dysfunction after radical surgery. Bladder disorders are also related to the extent of radical surgery. The neuropathopysiology of lower urinary tract symptoms after radical hysterectomy is not fully understood. Recent data have highlighted the role of urethral sphincter pressure in the etiology of postoperative incontinence. Various surgical approaches have been developed to preserve autonomic pelvic innervation. CONCLUSIONS: Nerve-sparing techniques appear to improve bladder function without compromising overall survival. Studies comparing the effects of nerve-sparing radical hysterectomy with standard surgery yielded encouraging results in respect of postoperative lower urinary tract function. Clinical trials with a long period of follow-up are required for better comprehension of the complex pathophysiology of bladder dysfunction after radical hysterectomy.

European content validation of the Self-Assessment Goal Achievement (SAGA) questionnaire in patients with overactive bladder.

INTRODUCTION AND HYPOTHESIS: The Self-Assessment Goal Achievement (SAGA) questionnaire is a patient-completed instrument designed to assess goal attainment in the behavioral or pharmacologic treatment of lower urinary tract symptoms (LUTS), including overactive bladder (OAB). The SAGA questionnaire allows patients to identify and rank the importance of treatment goals before treatment is initiated; the follow-up SAGA questionnaire quantifies the achievement of these patient-identified goals. The objective of this qualitative research was to confirm the content validity of the German, Spanish, Swedish, and English (UK) language versions of the SAGA questionnaire in patients with OAB with or without other LUTS. METHODS: The SAGA questionnaire was translated to each language in accordance with a well-established forward and backward harmonization method. Patient interviews were then conducted according to a cognitive debriefing methodology. Qualitative analysis of patients' input allowed assessment of content validity of each linguistically adapted SAGA questionnaire. RESULTS: All patients (n = 29; six to eight per targeted country) found the SAGA questionnaire easy to understand and to complete. Most patients completed the nine prespecified (fixed) treatment goals and were able to add up to five personal goals in the open-ended portion and rate each goal by importance. Differences were identified in how the various languages communicated some of the concepts assessed with the SAGA questionnaire. Rewording of the translated versions of the questionnaire was necessary in some cases. CONCLUSIONS: This linguistic content validation study in four European languages indicates that SAGA is a comprehensive, easy-to-understand, and relevant questionnaire for patient-completed evaluation of LUTS/OAB symptoms and treatment goal attainment.

The PISQ-IR: considerations in scale scoring and development.

INTRODUCTION: This paper provides a detailed discussion of the psychometric analysis and scoring of a revised measure of sexual function in women with pelvic floor disorders (PFD): the Pelvic Organ Prolapse Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). METHODS: Standard tools for evaluating item distributions, relationships, and psychometric properties were used to identify sub-scales and determine how the sub-scales should be scored. The evaluation of items included a nonresponse analysis, the nature of missingness, and imputation methods. The minimum number of items required to be answered and three different scoring methods were evaluated: simple summation, mean calculation, and transformed summation. RESULTS: Item nonresponse levels are low in women who are sexually active and the psychometric properties of the scales are robust. Moderate levels of item nonresponse are present for women who are not sexually active, which presents some concerns relative to the robustness of the scales. Single imputation for missing items is not advisable and multiple imputation methods, while plausible, are not recommended owing to the complexity of their application in clinical research. The sub-scales can be scored using either mean calculation or transformed summation. Calculation of a summary score is not recommended. CONCLUSION: The PISQ-IR demonstrates strong psychometric properties in women who are sexually active and acceptable properties in those who are not sexually active. To score the PISQ-IR sub-scales, half of the items must be answered, imputation is not recommended, and either mean calculation or transformed sum methods are recommended. A summary score should not be calculated.

Impact of overactive bladder treatment on the quality of life of patients over 60 with associated pathologies.

OBJECTIVES: To study the impact of treatments prescribed in usual practice to control Overactive Bladder (OAB) on health-related quality of life (HRQoL) of patients with associated pathologies. METHODS: 1.434 patients over 60 years with newly diagnosed OAB and at least one associated pathology (urinary or genital-skin infections, sleep disorders, depression, hypertension) were recruited in 300 urological/gynecological practices in Spain. During the first visit, socio-demographic and basic clinical information were registered and the therapeutic strategy for OAB was prescribed following usual clinical practice The patients filled out the HRQoL SF-12 questionnaire. On the second visit (4-6 months later) the HRQoL was re-evaluated. HRQoL was compared between sexes (Mann-Whitney) and between visits (Wilcoxon for related samples). Multiple regression models were performed in order to study the variables independently associated with HRQoL. RESULTS: Valid data is given for 1,274 patients for visit 1 and 1,153 for visit 2. 71.51% of the sample were female. Mean age was 68.17 (6.19). A significant improvement in the HRQoL was found on the second visit. Factors independently associated with lower score in both summary index of SF-12: first visit, female gender and Charlson Index. Additional factors associated with reduction of the physical component score: age, all associated pathologies and treatment using vaginal pessaries. Additional factors associated with the mental component score: treatment for depression, sleep disorders, use of vesical reeducation and the modification of treatment using diuretics. CONCLUSIONS. The treatments prescribed in usual clinical practice to alleviate OAB are effective in notably improving the HRQoL of patients in general, both physically and mentally.