Ultrasound assessment of urethral structure and bladder neck position in women with different parities.

INTRODUCTION AND HYPOTHESIS: The study aims to compare the urethral sphincter size and bladder neck position and mobility in women with different parities. METHODS: Women referred to the urodynamics clinic for lower urinary tract and prolapse symptoms were included in the study. A detailed history was taken, and transperineal two- and three-dimensional ultrasound was performed on all the women. The women were divided into four groups according to the vaginal parity. Group 1 had no vaginal childbirths. Group 2 had one, group 3 had two and group 4 had three or more vaginal childbirths. The data was analysed and compared among the groups. RESULTS: One hundred fifty women were included in the study. There were 34, 22, 48 and 46 women in groups 1 to 4 respectively. The distribution of different urodynamic diagnoses was similar in all four groups. The urethral sphincter measurements were significantly larger in the vaginally nulliparous group than in all other groups. The measurements were not smaller in multiparous women than in primiparous women. The bladder neck was at a lower position at rest in parous women than nulliparous women. The bladder neck movement was not more in groups 2 to 4 than in group 1. CONCLUSION: The urethral sphincter was smaller and the bladder neck position was lower in parous women than nulliparous women. These differences were not progressive with increasing parity. Request for elective caesarean section during the second pregnancy to protect the urethra is not supported by this study.

Does cystoscopy method affect the investigation of bladder pain syndrome/interstitial cystitis?

INTRODUCTION AND HYPOTHESIS: Cystoscopic investigation to identify associated histological findings of increased mast cells in the detrusor muscle has been recommended by the European Society for the Study of Bladder Pain Syndrome (ESSIC) in the investigation of bladder pain syndrome/interstitial cystitis (BPS/IC). The aim of this study was to identify if the cystoscopy approach impacts the biopsy results when investigating women presenting with symptoms of BPS/IC. METHODS: We performed a single-centre retrospective analysis of 300 bladder biopsy reports from 2015 to 2018 from women undergoing cystoscopy for BPS/IC. Biopsies obtained using closed cup forceps through a flexible (FC) or rigid cystoscope (RC) were compared. RESULTS: Fifty-eight FC biopsies were compared with 242 RC biopsies. FC biopsies had a smaller mean diameter (1.6 mm vs 2.9 mm p < 0.01) and volume (4.1 mm3 vs 9.6 mm3 p < 0.001) compared with RC biopsies. There was no significant difference in the histological depth of sampling to the muscularis propria. A total of 292 samples had CD117 immunohistochemical staining for mast cell count (MCC) analysis. The MCC/mm2 was significantly lower in FC biopsies (p < 0.01). Sixteen percent of FC samples compared with 60% of RC samples had a high MCC >28/mm2 (p < 0.01). There was no significant difference in positive microbiology culture between FC (21%) and RC (28%) sampling. CONCLUSION: Rigid and flexible cystoscopy can be used to investigate BPS/IC as recommended by international societies. However, the biopsy method impacts the mast cell count analysis, which can influence diagnosis and management. Therefore, RC would be the optimal investigation.

Anal canal to pubis angle: a novel clinical ultrasound technique for the assessment of the anorectal region.

INTRODUCTION AND HYPOTHESIS: Posterior compartment prolapse is associated with severe morbidity including faecal incontinence and defaecation dysfunction. The aim of this study was to develop and validate a novel ultrasound marker (anal canal to pubis angle) for the assessment of the anal axis in the context of posterior compartment prolapse in women and in controls (healthy, nulliparous, non-pregnant volunteers). METHODS: Anal canal to pubis (AC/Pubis) angle is measured with 2D transperineal ultrasound in precisely the midsagittal plane. The image was inverted and zoomed out and the angle opened to 107° (maximum). The image includes the pubis, urethra and anal canal. The angle measurement starts from the anal canal, pivots on the anorectal junction and ends at the shadow of the pubis. Inter- and intra-observer agreement in AC/Pubis angle measurement was assessed and the angles measured in the two groups compared. RESULTS: Forty women with posterior prolapse and 17 controls were included. Close agreement was observed in inter- and intra-observer AC/Pubis angle measurements assessed with Bland-Altman analysis. AC/Pubis angle is significantly wider in prolapse patients compared to controls (t-test, p < 0.001), with mean AC/Pubis angle in prolapse patients 122.9° (SD 15.6°) and controls 98.2° (SD 15.9°). CONCLUSION: The AC/Pubis angle is a novel validated 2D ultrasound technique for the assessment of the anorectal axis that potentially can be performed using equipment that is widely available in routine clinical practice. The AC/Pubis angle is significantly wider in prolapse patients compared to controls.

The use of 3D ultrasound in comparing surgical techniques for posterior wall prolapse repair: a pilot randomised controlled trial.

The most appropriate method for repairing posterior vaginal wall prolapse is still debatable. Women with symptomatic prolapse scheduled to undergo surgical repair in the posterior compartment were randomised to standard posterior colporrhaphy (SPC) or fascial and vaginal epithelial plication (FEP). Participants were assessed with the Prolapse Quality of Life (P-QOL) questionnaire, pelvic organ prolapse quantification (POP-Q) examination and three-dimensional ultrasound (3D US) prior to surgery and 6 months postoperatively. The research hypothesis is that 3D US of the pelvic floor is a reliable tool in comparing the anatomical outcomes of the two different surgical techniques. Differences in anatomical outcomes, assessed clinically and by ultrasonographic evaluation, were compared between the two groups using the Independent Mann-Whitney U-test and the Wilcoxon signed-rank sum test. Twenty-two women were included in the analysis. Six months postoperatively, women in the FEP arm had better anatomical outcomes compared to those who had undergone SPC (p = .02). Repeatability of the ultrasound technique was confirmed, showing moderate to very good agreement in all parameters and the 3D US evaluation was corroborated with the clinical examination, showing a greater reduction in the urogenital size in the FEP group.Impact statementWhat is already known on this subject? The low cost and universal availability of the ultrasound (US) makes it the most commonly used diagnostic modality. The ability to see beyond surface anatomy is important and useful in the assessment of the posterior vaginal wall prolapse and the obstructed defaecation, where this method may replace the defaecation proctography (Dietz 2019). Recent advances in pelvic floor ultrasonography (3D US) have achieved repeatability in the measurement of the levator hiatal (LH) dimensions, introducing a valid and readily available tool for researchers and clinicians (Dietz et al. 2005). Ultrasound may distinguish a true rectocele due to the weakening of the rectovaginal fascia from an enterocele, a rectal intussusception, or just a deficient perineum (Guzman Rojas et al. 2016).What do the results of this study add? Our study demonstrates that 3D translabial pelvic floor ultrasound is a useful and reliable tool in assessing the anatomical outcome of prolapse surgery.What are the implications of these findings for clinical practice and/or further research? Our study demonstrates that 3D translabial ultrasound of the pelvic floor is a useful and reproducible method in evaluating the anatomical outcomes of surgical repair for posterior wall prolapse. Genital hiatus (GH) and levator hiatus (LH) dimensions measured by ultrasound can be used as surrogate anatomical markers in comparing the efficacy of different surgical techniques.

Does size matter? Perineometer and digital examination of a model levator hiatus.

INTRODUCTION: Evaluation of the female pelvic floor muscles is commonly carried out with digital examination and assigning a modified Oxford scale score or vaginal manometry. Racial differences can influence the size of the levator hiatus (LH) with "black" or African nulliparous women having a significantly larger LH compared to Caucasian women. The aim of this study was to assess the impact of LH size on manometry readings of simulated pelvic floor muscle contractions (PFMCs) using a small and large model LH. METHODS: Small and large LH models were created using published data for size. Inflation of a pressure cuff placed circumferentially in the LH model represented a simulated PFMC. The models were examined in a supine position by three examiners and a perineometer twice each at varying simulated PFMC strength. RESULTS: Positive correlation was found between increasing simulated PFMC strength with a higher Oxford score following digital examination and manometry readings for both the small (rs = .87, rs = .98) and large (rs = .95, rs = .87) models. There was good to excellent inter and intraobserver correlation for digital assessment of both models. The manometry measurements showed a much larger incremental rise from baseline in the small model compared with the large model (P < .05). CONCLUSION: This study demonstrates that perineometer readings are affected by natural variations in LH size and PFMC strength. Therefore improvement to pelvic floor strength cannot be interpreted and measurements cannot be compared with others unless the LH size is known or digital examination is carried out.

Urethral sphincter volume and urodynamic diagnosis.

AIM: To compare urethral sphincter measurements in women with different urodynamic diagnoses using three-dimensional transperineal ultrasound (TPU). METHODS: Women with lower urinary tract dysfunction having urodynamic studies (UDS) were prospectively recruited to this study. A detailed history and vaginal examination were conducted. Saline cystometry was performed and the women were divided into groups according to their urodynamic diagnosis, which were nondiagnostic urodynamics (NUDS), pure detrusor overactivity (PureDO), pure urodynamic stress incontinence (PureUSI) and mixed urinary incontinence (MUDS). Three-dimensional TPU was performed to measure total urethral sphincter volume, striated sphincter volume, core volume, sphincter length and maximum cross-sectional area. The ultrasound measurements were compared with the diagnostic urodynamics. RESULTS: One hundred fifty women were included in the study. There were 37, 53, 22 and 38 women in the groups of NUDS, PureDO, PureUSI and MUDS respectively. The average striated sphincter volumes in these groups were 1.84 ml, 2.24 ml, 1.32 ml and 1.98 ml respectively. There was no difference in average age, body mass index or presence of prolapse in these groups. All measurements were larger in the PureDO and smaller in the PureUSI group compared with the NUDS group. The measurements in the MUDS group were larger than in the NUDS group and smaller than in the PureDO group but this difference was not statistically significant. CONCLUSION: The urethral sphincter of women with PureDO is larger than in women with PureUSI. The value in women with MUDS was between the two. The size of the urethral sphincter appears to be related to the pathophysiology.

Ultrasound imaging of the perineal body: a useful clinical tool.

INTRODUCTION AND HYPOTHESIS: The perineal body is a fibromuscular pyramidal structure located between the vagina and the anus. It has been difficult to image because of its small size and anatomical location. This study used 2D transperineal ultrasound to measure the perineal body and assess whether there is an association with prolapse. METHODS: An observational, cross-sectional study was carried out in a tertiary level Urogynaecology department and included prolapse patients and healthy nulliparous volunteers (control group). This was a clinical assessment, including POP-Q and trans-perineal 2D ultrasound measurement of the perineal body height, length, perimeter, and area. Parametric tests were used, as the data were normally distributed. Results are reported as mean and 95% confidence interval (±95% CI). RESULTS: A total of 101 participants were recruited of which 22 were nulliparous healthy volunteers. Mean perineal body measurements in controls were height 22.5 ± 3.3 mm, length 17.4 ± 2.7 mm, perimeter 7.5 ± 0.9 mm, and area 2.8 ± 0.38 cm2. Perineal body measurements in 79 prolapse patients: height 16.9 ± 1.7 mm, length 16.0 ± 1.4 mm, perimeter 6.5 ± 0.5 mm and area 2.1 ± 0.5 cm2. A small perineal body was strongly associated with posterior compartment prolapse (paired t test, p < 0.0001) and wider POP-Q GH (paired t test, p = 0.0003). Surprisingly, Pelvic Organ Prolapse Quantification Perineal Body (POP-Q PB) of the two groups was not significantly different. A perineal body mid-sagittal area of less than 2.4 cm2 has been shown to be associated strongly with posterior compartment prolapse. CONCLUSIONS: It is possible to measure the perineal body on 2D ultrasound. This technique facilitates the objective diagnosis of perineal deficiency. POP-Q PB does not predict the length or area of the perineal body.

Posterior tibial nerve stimulation for overactive bladder-techniques and efficacy.

The ideal treatment for overactive bladder is still elusive. In those where medication fails to improve symptoms options include invasive treatments such as botulinum toxin-A, sacral neural stimulation or posterior tibial nerve stimulation. Scientific professional society guidelines advise percutaneous posterior tibial nerve stimulation as a third line treatment option only after multi-disciplinary team review as well as failure of both conservative and pharmacological management. The aim of this article is to review all techniques for tibial nerve stimulation and their efficacy.

Ultrasound technique for the assessment of urethral descent assessment technique (UDAT) in healthy volunteers.

Bladder neck descent (BND) has been implicated in the pathophysiology of stress incontinence and prolapse. The aim of this study was to evaluate a novel 2D technique for the evaluation of BND, the Urethral Descent Assessment Technique (UDAT). UDAT involves measuring BND during dynamic manoeuvres in live 2D ultrasound, by using the geometrical properties of parallel lines. The internal urethral meatus and distal end of the urethra are used as reference points. Y1 is the urethral height at rest (also the urethral length when the urethra is straight). Y2 is the urethral height on Valsalva. Y1 and Y2 are parallel lines. Y1-Y2 = BND. A horizontal line (X) connecting Y1 and Y2 is the forward movement of the bladder neck.Y1 mean 30.4 mm (95% CI ± 1.36 mm). Y2 mean 24.2 mm (95% CI ± 2.58 mm). X mean 12.1 mm (95% CI ± 1.66 mm). BND mean 6.2 mm (95% CI ± 1.47 mm). Bland-Altman plots and linear regression showed that UDAT is repeatable and reliable.Impact statementWhat is already known on this subject? Bladder neck descent (BND) has been associated with stress incontinence and prolapse nearly a century. In 1975, Green introduced a classification based on X-ray cysto-urethrograms. Between 1989 and 1995, a 2D technique was described that had several limitations.What do the results of this study add? This study validates a novel technique for the assessment of bladder neck descent using 2D ultrasound and provides a reference range of BND for normal nulliparous women.What are the implications of these findings for clinical practice and/or further research? This is a simple and quick technique that could be adopted in research and clinical practice in the future to assess stress incontinence and anterior compartment prolapse.

Levator Ani avulsion: The histological composition of this site. A cadaveric study.

INTRODUCTION: The sonographic appearance of a levator muscle "avulsion" representing the literal detachment of the pubovisceral muscle (PVM) enthesis has been contested. The nature of the levator ani "avulsion" is still not fully understood. It is known, that the tensile strength of a tendon is dependent on collagen with increased synthesis of collagen occurring in tissue with increased mechanical load levels. This study aims to perform a quantitative histological evaluation of the PVM enthesis with or without the imaging finding of levator ani "avulsion" to determine if there is a difference in the proportion of muscle and collagen. METHOD: Three-dimensional translabial ultrasound for PVM "avulsion" was performed on cadavers using a GE Voluson I with a 5-9 MHz electronic probe. Cadavers were meticulously dissected to identify the presence or absence of an anatomical avulsion. The PVM enthesis was excised for further histopathological processing and treated with three different colorations. Quantitative analysis using ImageJ software was conducted to compare tissue composition in samples with or without sonographic "avulsion." All stages were performed by two separate investigators blinded to each other's results. The results were analyzed using SPSS v24, IBM. RESULTS: Twenty-three PVM enthesis with histological staining were procured. Ultrasonographic "avulsions" were seen in 5/23 PVM enthesis. No anatomical avulsions were seen. There was no difference in the overall muscle or collagen content (Kruskal-Wallis, P = 0.864). The mean organized skeletal muscle content was 23% in the sonographic "avulsion" group versus 62% in the no "avulsion" group (Kruskall-Walis, P = 0.02). "Avulsions" were associated with a disorganized appearance at histology. CONCLUSION: The tissue composition relating to the proportion of muscle and collagen was not significantly different in specimens with or without sonographic "avulsions." However, morphological differences were observed in the organization of the muscle fibres, which requires further evaluation.

The impact of bariatric surgery on urinary incontinence: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Obesity and overweight are strongly associated with stress and urgency urinary incontinence, and weight loss has been associated with improvement in urinary incontinence. We aimed to measure pooled effect sizes for different weight loss procedures on incontinence-specific quality of life and incontinence cure rate in a systematic review and meta-analysis. METHODS: MEDLINE, Embase and the Cochrane library were searched using a pre-defined strategy for relevant cohort studies. Random effects meta-analyses were conducted for the weighted mean difference for urinary quality of life scores and weighted overall pooled estimates for proportions of women cured. We explored heterogeneity using meta-regression, testing the type of bariatric surgery and change in BMI as predictors of effect size. The studies were categorised as either low or high risk of bias using a novel instrument specifically designed for longitudinal symptom research studies. RESULTS: Twenty-three studies (n = 3,225) were included. Incontinence-specific quality of life scores were improved by 14% (weighted mean difference = -14.79; CI = -18.47 to -11.11; I2 = 87.1%); the proportion of women cured of any urinary incontinence was 59% (95% CI = 51 to 66%) and the proportion of women cured of stress urinary incontinence was 55% (95% CI = 40 to 70%). CONCLUSIONS: Bariatric surgery results in clinically meaningful improvements in incontinence-specific quality of life. Current data are limited by both short-term follow-up and unexplained heterogeneity among studies.

Validation study of ultrasound bladder wall thickness measurements.

INTRODUCTION AND HYPOTHESIS: The aim was to validate ultrasound bladder wall thickness measurements. We scanned at three frequencies (5 MHz, 7 MHz and 9 MHz), using two techniques described in clinical practice and compared them with direct micrometre calliper measurements. METHODS: Bladder dome cadaver specimens were dissected from male and female cadavers. The direct micrometre calliper measurement under direct vision was used as the gold standard. We imaged using a Voluson E8 ultrasound scanner at three frequencies, using three probes: AB27D (2-7 MHz), RAB25D (2-5 MHz) and RIC50D (5-9 MHz). The specimens were scanned on two different occasions for intra-observer variability. A second operator, measured the samples again independently for the interobserver agreement. The specimens were gently placed onto a sheathed and gelled probe to avoid deformation. The method of scanning was the same for all the specimens, probes and operators. RESULTS: Twenty-five bladder dome specimens were assessed. The correlation of the ultrasound measurement to the direct measurement improved at higher ultrasound frequencies. Measuring from the inside of the serosal hyperechogenicity also increased the accuracy correlation with the direct measurement for all the frequencies tested. CONCLUSIONS: This is the first study validating BWT ultrasound measurements against cadaveric bladder wall calliper measurements. Technology and technique affect accuracy, which is important in clinical practice. The use of 5-MHz probes is not recommended. The most accurate measurement was obtained using high-frequency ultrasound, where the measurement did not include the serosal brightness. These data suggest that high-frequency ultrasound should be used to assess BWT.

Urodynamics are necessary for patients with asymptomatic pelvic organ prolapse.

AIM: To evaluate the role of pre-operative urodynamics in women with pelvic organ prolapse, who are asymptomatic for urinary symptoms. Correlate urodynamics findings with King's Health Questionnaire (KHQ) responses. MATERIALS AND METHODS: Retrospective review of prospectively collected data on routine pre-operative urodynamics investigations in women with urogenital prolapse requiring surgery. Patients who were reported to be asymptomatic of urinary symptoms at the urogynaecological clinical consultation, were included for analysis. KHQ and urodynamics data were reviewed. RESULTS: A 800 records of women having routine pre-operative urodynamics were collected over a 10-year period, were reviewed. 98/800 (12%) were aymptomatic of urinary symptoms and underwent urodynamics. 82/98 (84%) completed the KHQ. 48/98 (49%) had normal urodynamics. 30/98 (31%) had detrusor overactivity (DO). 17/98 (17%) showed occult urodynamic stress incontinence (USI). 3/98 (3%) both DO and USI. 28/98 (29%) had peak flow rate less than 15 mL/s. Forty-five percent of women reporting nocturia had DO. Nine percent had over 100 mL residuals after the free flow study. Routine pre-operative urodynamics changed management in 25/98 (25%) of asymptomatic prolapse patients. TVT was performed in 12 patients. One patient who declined TVT for moderate occult USI, developed new-onset stress urinary incontinence post-operatively. CONCLUSION: This data show, that an accurate pre-surgical evaluation of patients with prolapse is incomplete without a structured validated questionnaire and urodynamics, due to the high proportion of abnormal KHQ and UDS findings in presumably "asymptomatic" patients.

Urinary Metabolic Phenotyping of Women with Lower Urinary Tract Symptoms.

Lower urinary tract symptoms (LUTS), including urinary incontinence, urgency and nocturia, affect approximately half of women worldwide. Current diagnostic methods for LUTS are invasive and costly, while available treatments are limited by side effects leading to poor patient compliance. In this study, we aimed to identify urine metabolic signatures associated with LUTS using proton nuclear magnetic resonance (1H NMR) spectroscopy. A total of 214 urine samples were collected from women attending tertiary urogynecology clinics (cases; n = 176) and healthy control women attending general gynecology clinics (n = 36). Despite high variation in the urine metabolome across the cohort, associations between urine metabolic profiles and BMI, parity, overactive bladder syndrome, frequency, straining, and bladder storage were identified using KODAMA (knowledge discovery by accuracy maximization). Four distinct urinary metabotypes were identified, one of which was associated with increased urinary frequency and low BMI. Urine from these patients was characterized by increased levels of isoleucine and decreased levels of hippurate. Our study suggests that metabolic profiling of urine samples from LUTS patients offers the potential to identify differences in underlying etiology, which may permit stratification of patient populations and the design of more personalized treatment strategies.

The location of pain and urgency sensations during cystometry.

AIMS: The relationship between bladder pain and urinary urgency sensations is poorly understood. We analyzed the relationship between locations and intensities of urgency and pain sensations felt during filling cystometry. METHODS: Participants completed the King's Health Questionnaire (KHQ) to indicate presence of bladder pain or urgency. During cystometry, participants scored the intensity of urgency and pain, both in the suprapubic and the urethral region, on a VAS scale of 0-10 at a baseline, at first desire, normal desire, strong desire to void, and at maximum cystometric capacity during filling. We allocated the participants to six groups; those reporting urgency or not, pain or not, both symptoms and neither. Friedman's Test was used to ascertain if all scores increased significantly, the Wilcoxon Signed Rank Test was used to demonstrate the difference between scores, and agreement for findings during cystometry was tested with Mann-Whitney U. RESULTS: A total of 68 women participated; 38 participants reported pain, 57 reported urgency, and 33 reported both symptoms. Pain and urgency scores significantly increased during cystometry (P < 0.0001). For participants reporting pain, suprapubic pain was rated significantly higher than urethral pain. Participants reporting both symptoms, felt more urgency than pain, and again pain more suprapubically than urethrally. Participants reporting only urgency scored suprapubic and urethral urgency similarly at all desires. CONCLUSIONS: Pain and urgency are well differentiated sensations and are felt at different locations although pain is seemingly easier localized. Neurourol. Urodynam. 36:620-625, 2017. © 2016 Wiley Periodicals, Inc.

Does the vaginal wall become thinner as prolapse grade increases?

INTRODUCTION AND HYPOTHESIS: The pathophysiology of prolapse is not well understood. However, two main theories predominate: either the fibromuscular layer of the vagina develops a defect/tears away from its supports, or its tissues are stretched and attenuated. The aim of this study was to assess how vaginal wall thickness (VWT) is related to vaginal prolapse. METHODS: The study group comprised 243 women with symptomatic prolapse recruited from the Outpatient Department of a tertiary referral centre for urogynaecology. A history was taken and women were examined to determine their POP-Q score. Using a previously validated technique, ultrasonography was used to measure the mean VWT at three anatomical sites on the anterior and posterior walls. Scores were then compared using t tests, the Kruskal-Wallis test and the Friedman test. RESULTS: The mean age of the patients was 59.7 years (SD 12.0 years range 38 - 84 years). For each measurement VWT reduced as prolapse grade increased until the prolapse extended beyond the hymen. Women with grade 3 prolapse had a significantly higher mean VWT than women with grade 1 or 2 contained prolapse. Menopause status did not have a significant effect on the VWT. CONCLUSIONS: VWT is lower in women with vaginal prolapse until the prolapse extends beyond the hymen and then VWT is thicker and comparable with women without prolapse. This may be explained by changes in the vaginal tissue including reduction of collagen, elastin and smooth muscle, as well as fibrosis in exposed tissues, rather than by defects in the vagina.

Reliability and validity of urinary nerve growth factor measurement in women with lower urinary tract symptoms.

INTRODUCTION AND HYPOTHESIS: The validity and reliability of measurement of urinary NGF as a diagnostic biomarker in women with lower urinary tract dysfunction (LUTD) is uncertain. We aimed to evaluate both the diagnostic and discriminant validity, and the test-retest reliability of urinary NGF measurement in women with LUTD. METHODS: Urinary NGF was measured in women with LUTD (n = 205) and asymptomatic subjects (n = 31). Urinary NGF was assayed using an ELISA method and normalized against urinary creatinine. NGF/creatinine ratios were compared between symptom subgroups using Mann-Whitney U test, and between different urodynamic diagnoses using the Kruskal-Wallis test. Receiver Operator Characteristic (ROC) analysis was employed to evaluate the diagnostic performance of urinary NGF. Test-retest reliability of NGF measurement was assessed using intra-class correlation (ICC). RESULTS: Urinary NGF was significantly but non-specifically increased in symptomatic patients when compared to controls (13.33 vs. 2.05 ng NGF/g Cr, P < 0.001). On multivariate logistic regression NGF was a good predictor of patients having OAB or not, however, the adjusted odds ratio only 1.006. ROC analysis demonstrated poor discriminant ability between different symptomatic groups and urodynamic groups. Using a cut off of 13.0 ng NGF/g creatinine the test provides a sensitivity of 81%, but a specificity of only 39% for overactive bladder. The assays demonstrated good test-retest reliability with ICC of 0.889. CONCLUSIONS: Although urinary NGF can be reliably assayed, and is increased in various LUTDs, it discriminates poorly between these disorders therefore has very limited potential as a biomarker. Neurourol. Urodynam. 35:944-948, 2016. © 2015 Wiley Periodicals, Inc.

Association between joint hypermobility and pelvic organ prolapse in women: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Abnormalities of common collagen proteins have been noted in individuals affected by POP and JHM, suggesting a common aetiology. We assessed strength, consistency and potential for bias in pooled associations of the relationship between JHM and POP. METHODS: We searched MEDLINE, EMBASE and CINAHL, as well as International Continence Society (ICS) and International Urogynaecologic Association (IUGA) annual meeting abstracts, including reference lists, without language restrictions. We included case-control and cohort studies and applied strict criteria for choosing eligible studies. Methodologically trained reviewers independently screened abstracts and full texts to confirm eligibility. We extracted data on study and patient characteristics, clinical assessment tools, and methodology. We assessed comparability and representativeness of source populations, confidence in the assessment of JHM and POP and adjustment for confounding and missing data. Meta-analysis was performed using a random effects model. RESULTS: We retrieved 39 full texts, of which 14 were used in the meta-analysis. Overall pooled odds ratio (OR) was 2.37 [95 % confidence interval (CI) 1.54-3.64, I(2) = 77.0 %]. We identified no significant factors in meta-regression, and there was no evidence of publication bias; six studies were at high risk of bias with frequent differences in sampling frames, limited validity for clinical assessments and failure to match for important prognostic variables. CONCLUSIONS: We found a strong association between POP and JHM, with an effect size that is clinically relevant. Our findings are limited by high heterogeneity and the potential for residual confounding factors. JHM is an important early indicator for POP risk, and future longitudinal studies should explore the shared aetiology.

The FIGO assessment scoring system (FASS): a new holistic classification tool to assess women with pelvic floor dysfunction: validity and reliability.

INTRODUCTION AND HYPOTHESIS: The aim of our study was to assess the interobserver and intraobserver reliability as well as the content and construct validity of the FIGO prolapse assessment scoring system (FASS). METHODS: Women with and without (controls) symptoms of pelvic organ prolapse (POP) attending gynaecology outpatient clinics in four different countries were recruited prospectively. Each woman was assessed using the FASS which included: (1) physical examination findings designated with the letter P; (2) presence of symptoms of prolapse, urinary and bowel symptoms designated with the letter S; and (3) assessment of degree of bother designated with the letter B. A scoring system was also developed. For interobserver reliability women were examined by two separate examiners using the FASS. For intraobserver reliability the FASS was repeated by the same examiner within 2 weeks. The interclass correlation coefficient (ICC) was also calculated to assess limits of agreements. Validity was assessed by comparing the FASS scores between symptomatic and asymptomatic women using the Mann-Whitney U test (p value <0.001). RESULTS: A total of 177 women (98 symptomatic and 79 controls) were recruited. Intraobserver reliability had ICCs between 0.716 and 1. Interobserver reliability had ICCs between 0.795 and 0.909. Domain and total scores were significantly different between symptomatic and asymptomatic women (p < 0.001, Mann-Whitney U test). There was a good correlation between FASS P scores and POP-Q scores (rho 0.763, p < 0.001). CONCLUSIONS: The FIGO prolapse assessment scoring system has good intraobserver and interobserver agreement and has demonstrated both content and construct validity.