Natural progression of anal incontinence after childbirth.

INTRODUCTION AND HYPOTHESIS: The aim of work is to study the natural progression of anal incontinence (AI) in women 10 years after their first delivery and to identify risk factors associated with persistent AI. METHODS: A prospective cohort study of 304 primiparous women with singleton, cephalic delivery giving vaginal childbirth in 1995. Questionnaires distributed and collected at delivery, 9 months, 5 years and 10 years after, assessing anorectal symptoms, subsequent treatment, and obstetrical events. RESULTS: Women, 246 of 304, answered all questionnaires (81%). Thirty-five of 246 (14%) had a sphincter tear at the first delivery. One hundred ninety-six of 246 (80%) women had additional vaginal deliveries and no caesarean sections. The prevalence of AI at 10 years after the first delivery was 57% in women with a sphincter tear and 28% in women, a nonsignificant increase compared to the 5-year follow-up. Women who sustained a sphincter tear at the first delivery had an increased risk of severe AI (RR 3.9, 95% CI 1.3-11.8). Neither age, nor subsequent deliveries added to the risk. Severe AI at baseline and 5 years after delivery were independently strong predictors of severe AI at 10 years (RR 12.6, CI 3.3-48.3, and RR 8.3, CI 3.9-17.8, respectively). CONCLUSION: Persistent anal incontinence 10 years after the first parturition is frequent and sometimes severe, especially if vaginal delivery was complicated by an anal sphincter disruption.

Follow-up after treatment of cervical intraepithelial neoplasia by human papillomavirus genotyping.

OBJECTIVE: To assess the use of human papillomavirus genotyping in cervical intraepithelial neoplasia posttreatment follow-up. STUDY DESIGN: Prospective observational study. Ninety women underwent cytologic testing and human papillomavirus genotyping at the follow-up visit after conization. Cones were retrospectively genotyped. A second cytologic follow-up was performed. RESULTS: Margin status and presence of cervical intraepithelial neoplasia 3+ in the cone were poor predictors of treatment outcome (sensitivity, < 50%; diagnostic odds ratio,

p16(INK4a) immunocytochemistry in liquid-based cervical cytology: is it feasible for clinical use?

A consecutive series of 118 samples from patients referred to colposcopy assessment and follow-up with cytology and biopsies were analysed with immunocytochemical staining to determinate the expression of p16(INK4a). Accumulation of p16(INK4a) antigen has been proposed as a biomarker helpful for the identification of dysplastic cervical cells. In our study all benign cases were negative for p16(INK4a), while more than half of the high grade lesions showed moderate or strong reactivity. There was a correlation between CIN grade and p16(INK4a) expression levels with more advanced lesions showing stronger reactivity. The correlation between p16(INK4a) immunoreactivity and the severity of cytological abnormality was stronger, when the diagnosis was based on simultaneous routine cytology (p<0.001, chi(2) exact test for trend). There was no or weak reactivity in benign cases, as well as almost all low-grade lesions, while two thirds of high-grade lesions showed moderate or strong staining for p16(INK4a) antigen. Thus p16(INK4a) expression analysis yielded information which is consistent with results from the histopathology and is a simple way of emphasizing the presence of premalignant cell reactive atypias. This staining can be applied to cytological samples, and might be a complement prognostic procedure in order to find women at risk for cervical cancer.

Urinary incontinence after hysterectomy--three-year observational study.

OBJECTIVES: To perform a prospective evaluation of the long-term effects of hysterectomy on symptoms of urinary incontinence. METHODS: A prospective observational cohort study was performed. Preoperatively, 120 consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire on symptoms associated with urge and stress urinary incontinence. Of the 120 patients, 44 underwent vaginal and 76 abdominal hysterectomy. Follow-up questionnaires were administered at 1 and 3 years postoperatively. RESULTS: Postoperatively, the questionnaire was answered by 115 (96%) of 120 patients after 1 year and by 107 (89%) after 3 years of follow-up. At surgery, the mean patient age was 49.5 years (range 32 to 78). In the abdominal hysterectomy cohort, a tendency was found for decreased episodes of urinary incontinence, although the difference was not significant. No significant changes were noted in micturition frequency. In the vaginal hysterectomy cohort, no significant changes were detectable in the symptoms associated with urge or stress incontinence, and no significant changes were noted in micturition frequency. For the entire hysterectomy group, a significant decrease occurred in stress urinary incontinence symptoms (P = 0.03). Subgroup analysis did not identify any particular risk factors for the development of urinary incontinence after hysterectomy. CONCLUSIONS: In contrast to the results of several studies, the results of our 3-year prospective study showed that total hysterectomy, independent of route, was not associated with an increase in urge or stress urinary incontinence symptoms.

Long-term outcome of abdominal sacrocolpopexy using xenograft compared with synthetic mesh.

OBJECTIVES: To assess the clinical outcome after abdominal sacrocolpopexy using a porcine dermal graft compared with a synthetic mesh. METHODS: Patients with vaginal vault prolapse Stage II or worse (Baden-Walker staging), underwent sacrocolpopexy using a synthetic mesh (n = 25) or porcine collagen graft (n = 27). The subjective outcome was measured using validated questionnaires. RESULTS: The mean clinical follow-up from surgery was 7.1 months for the xenograft compared with 7.4 months for the synthetic cohort. At clinical follow-up, vaginal vault prolapse Stage II was present in 8 (29%) of 27 patients in the xenograft cohort and 6 (24%) of 25 patients in the synthetic mesh cohort (no significant difference). The mean follow-up from surgery to survey was 2.5 years in the xenograft cohort and 4.3 years in the synthetic cohort. None of the patients in either cohort had undergone a secondary sacrocolpopexy. No significant differences were found between the cohorts regarding surgical morbidity other than more patients experiencing fever for 1 to 3 days in the xenograft cohort (P < 0.001). No significant differences were found in lower urinary tract symptoms, anorectal symptoms, or quality-of-life variables between the two cohorts. CONCLUSIONS: Abdominal sacrocolpopexy using a porcine dermal graft was comparable to synthetic mesh in terms of subjective and anatomic outcomes at mid to long-term follow-up.

Anal incontinence after vaginal delivery: a five-year prospective cohort study.

OBJECTIVE: The long-term prevalence of anal incontinence after vaginal delivery is unknown. The aim of the present study was to evaluate the prevalence of anal incontinence in primiparous women 5 years after their first delivery and to evaluate the influence of subsequent childbirth. METHODS: A total of 349 nulliparous women were prospectively followed up with questionnaires before pregnancy, at 5 and 9 months, and 5 years after delivery. A total of 242 women completed all questionnaires. Women with sphincter tear at their first delivery were compared with women without such injury. Risk factors for development of anal incontinence were also analyzed. RESULTS: Anal incontinence increased significantly during the study period. Among women with sphincter tears, 44% reported anal incontinence at 9 months and 53% at 5 years (P = .002). Twenty-five percent of women without a sphincter tear reported anal incontinence at 9 months and 32% had symptoms at 5 years (P < .001). Risk factors for anal incontinence at 5 years were age (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0-1.2), sphincter tear (OR 2.3; 95% CI 1.1-5.0), and subsequent childbirth (OR 2.4; 95% CI 1.1-5.6). As a predictor of anal incontinence at 5 years after the first delivery, anal incontinence at both 5 months (OR 3.8; 95% CI 2.0-7.3) and 9 months (OR 4.3; 95% CI 2.2-8.2) was identified. Among women with symptoms, the majority had infrequent incontinence to flatus, whereas fecal incontinence was rare. CONCLUSION: Anal incontinence among primiparous women increases over time and is affected by further childbirth. Anal incontinence at 9 months postpartum is an important predictor of persisting symptoms.