Retrospective review of history vs. ePAQ-PF in complex urogynaecology patients.

INTRODUCTION AND AIM OF THE STUDY: Urinary incontinence and prolapse are debilitating conditions significantly affecting quality of life. They are extremely prevalent, affecting a significant number of women attending gynaecology clinics with complex symptoms. ePAQ-PF offers a user-friendly clinical tool, which provides valid and reliable data. The system offers comprehensive symptoms and quality of life evaluation which is an advantage over history and may enhance the clinical episodes detection as well as the quality of care for women with pelvic floor disorders. The aim of the study is to compare effectiveness of ePAQ-PF against history for diagnosis in complex urogynaecology patients. MATERIALS AND METHODS: Data was collected retrospectively from ePAQ-PF and history in a tertiary level urogynaecology unit and collated onto microsoft excel. 40 patients were selected randomly from 56 eligible (administered and succeessfully completed ePAQ-PF) patients attending Urogynaecology and PEARL (combined urogynaecology and colorectal) clinics between July 2018 and July 2021. Fisher's exact test was used for inferring on statistical significance in the comparative analysis. The software used for this analysis was SAS version 9.4. RESULTS: Thirty-four out of the forty patients were eligible for analysis for overactive bladder and stress urinary incontinence; twenty-four for prolapse and twenty-six patients for voiding difficulty. Patients were between 18 and 80 years of age with highest participants between 40 and 69 years. Four scored symptom domain was chosen for statistical analysis due to adequate power of comparative data in these domains. The additional diagnostic yield by ePAQ-PF for overactive bladder (OAB), stress urinary incontinence (SUI), voiding difficulty (VD) and prolapse was 26.47%, 0%, 67% and 16.67% respectively. P value for OAB, VD and prolapse was 0.0294, 0.0031 and 0.01 respectively. Apart from these four symptoms ePAQ-PF contributed additional symptoms over and above history in all 40 patients due to its wide range of symptom domains. History provided additional symptoms in 3 women with recurrent urinary tract infection which was not identified on ePAQ-PF. INTERPRETATION OF RESULTS: ePAQ-PF has shown significant additional diagnostic yield for overactive bladder, voiding difficulty and prolapse. P value for each has supported this statement. Although there was no additional diagnostic yield for stress urinary incontinence by ePAQ-PF, it has shown an accuracy of 96.97% (n = 33) for diagnosing the cases like history taking for SUI. ePAQ-PF enabled us to identify more symptoms in 100% cases (n = 40) which includes body image, general sex life, pain and altered sensation of vagina, reduced capacity of vagina etc, in comparison to history, for complex urogynaecology patients. History contributed to additional symptom diagnosis such as recurrent urinary tract infection in 7.5% (n = 40) of cases. CONCLUSION: ePAQ-PF is a useful diagnostic tool providing additional benefit for the diagnosis of the complex urogynaecology patient. Overall recommendation is to implement a policy of using ePAQ-PF evaluation in all complex urogynaecology patients in addition to history. Further studies are needed to assess the pattern of the yield across age, parity, disease severity related to complex urogynaecology symptoms.

Evaluation of the Anopress® device in assessment of obstetric anal sphincter injuries in a specialist urogynaecology service.

OBJECTIVES: THD Anopress® is a new portable anal manometry device which can be used in an outpatient clinic setting. In this study, we aimed to: STUDY DESIGN: A retrospective analysis was conducted of women with OASI seen in a specialist clinic at 3- and 6-months post-delivery from November 2016 to December 2019. 72 women who attended their 6-month appointment and underwent anal manometry with Anopress were included. St Mark's Faecal incontinence score (FI) was calculated and for the purpose of analysis patients were classified into two groups - FI score less than 5 and 5 or more. EAUSS findings were classified as sphincter defect or no defect. RAVP and MSP were measured with Anopress and compared with the variables (symptoms and EAUSS findings) using the Mann-Whitney U test. RESULTS: A total of 72 women were included in the study. There were 19 (27 %), 41 (57 %), 6 (8 %) and 6 (8 %) 3a, 3b, 3c and 4th degree perineal tears respectively. The median RAVP was 17 mm Hg (Inter-Quartile Range 10.75-24 mmHg) and median MSP was 47.5 mm Hg (IQR 33-68 mmHg). 38 patients (53 %) had a demonstrable sphincter defect on EAUSS. 37 patients (51.3 %) had FI score < 5 and 35 patients (48.6 %) had FI score of 5 or more. RAVP and MSP were significantly lower with EAUSS demonstrable sphincter defect (p < 0.001). Symptom severity correlated with RAVP (p = 0.016) though its correlation with MSP was not statistically significant (p = 0.096). CONCLUSION: Anopress seems promising in the assessment of anal sphincter function in women with OASI and can potentially make anal manometry testing easily accessible to urogynecologists.

Predictors of patient preference for mode of delivery following an obstetric anal sphincter injury.

OBJECTIVES: Patients who sustain an Obstetric Anal Sphincter Injury (OASI) have the opportunity to select an elective caesarean section over a vaginal delivery in subsequent pregnancies. It remains unclear whether there are identifiable factors which predict expectant mothers' choices. The primary aim of our study was to explore this issue further in a consecutive group of patients who had suffered OASI. STUDY DESIGN: Data were retrospectively collected for patients attending a specialist OASIS clinic between July 2016 and February 2018. Information routinely collected in clinical practice was considered including mode of previous delivery, severity of OASI, combined with anal incontinence symptoms and endoanal ultrasound results. Logistic regression analysis was used to explore the relationship between these variables and the preferred mode of delivery. RESULTS: A total of 188 patients were identified of whom 153 had complete data for analysis. Approximately 30% (n = 45) of patients preferred to have a caesarean section in their subsequent pregnancy. Bivariate analysis revealed significant associations between choosing a caesarean section in subsequent pregnancy and individuals with major tears (p = 0.001), high anal incontinence scores (p = 0.001) and defects on endoanal ultrasound (p < 0.001). Logistic regression analysis showed statistically significant associations between Caucasian ethnicity (Odds ratio (OR) 12.6, 95% CI 2.4-69.9) and endoanal ultrasound results (OR 2.3, 95% CI 1.7-3.2) with preference for caesarean section. CONCLUSION: Our data suggests that emphasis is placed by patients on endoanal ultrasound results when making their decision about mode of delivery in a subsequent pregnancy, suggesting a useful application of this tool. Ethnicity is a strong predictor of choice of delivery after OASI and may be potentially useful in forecasting maternity unit services.

The use of Episcissors-60 to reduce the rate of Obstetric Anal Sphincter Injuries: A systematic review.

OBJECTIVES: The aim of this systematic review is to evaluate the effect of Episcissors-60, which were designed to improve the accuracy of episiotomies, on the rate of Obstetric Anal Sphincter Injuries. STUDY DESIGN: This review is registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42018094935). A literature search of the PubMed, Embase and Cochrane databases was performed from inception to May 2018. All peer-reviewed studies evaluating the use of Episcissors-60 in clinical practice and the resulting Obstetric Anal Sphincter Injury incidence were included. Data on study population demographics, incidence of Obstetric Anal Sphincter Injuries, rate of episiotomies and angle of episiotomy achieved while using the Episcissors-60 were recorded. RESULTS: A total of seven studies were identified, five of which were included in the review. A total of 3509 women of whom 1050 had episiotomies performed. Included studies demonstrated that introduction of Episcissors-60, when combined with other preventative measures including manual perineal support at delivery, can reduce Obstetric Anal Sphincter Injuries by up to 50%. In all studies, operators were able to consistently achieve post-suturing episiotomy angles of more than 40°. An increase in episiotomy rates, especially during spontaneous vaginal deliveries, was also reported. CONCLUSION: The results of this systematic review support the use of Episcissors-60, combined with other preventative measures, to reduce the incidence of Obstetric Anal Sphincter Injuries.

Normative bladder diary measurements in pregnant women.

OBJECTIVE: Studies have demonstrated a strong positive correlation between bladder capacity and total volume voided in asymptomatic non-pregnant women. Therefore, to adequately characterise the normative data, it was important to compare bladder capacity vs. 24-h volume (V24) relationships in our pregnant study population. Our objectives were to (1) collect normative bladder diary measurements from asymptomatic primigravid women, (2) investigate the relationship between these measurements and gestation of pregnancy, and (4) compare these normative measurements from pregnant women with those from asymptomatic non-pregnant women. We focused on measures of "bladder capacity" [average ("Vavg") and maximum volume per void ("Vmax")], ("V24"), and voiding frequency ("F24"). STUDY DESIGN: Three-day bladder diaries were collected from 41 primigravid women, one three-day diary per trimester. We compared our pregnant data with non-pregnant data previously collected by Amundsen et al. using identical methods. Relationship between variables analysed using the Kruskal-Wallace and Mann-Whitney tests. RESULTS: We found no significant differences across trimesters among bladder diary measurements (p-values: F24=0.711;Vmax=0.912;Vavg=0.894, and V24=0.675). A comparison between pregnant and non-pregnant data showed no significant difference between F24, but a significantly lower V24, Vavg and Vmax in pregnant women. Regression analysis showed no significant differences between the pregnant and non-pregnant, V24 vs. bladder capacity relationships. CONCLUSIONS: Pregnancy results in smaller bladder capacities and lower V24, with a normal relationship between V24 and bladder capacity, maintaining normal voiding frequency. We used our data to construct a nomogram to help clinicians compare the relative contributions of increased V24 and reduced bladder capacity to increased F24.

Does vaginal estrogen treatment with support pessaries in vaginal prolapse reduce complications?

OBJECTIVE: Pelvic organ prolapse is often co-existant with atrophy of the genital tract in older women who tend to prefer vaginal pessaries for prolapse. Vaginal estrogen therapy is used by some along with a support pessary for prolapse with no robust evidence to back this practice. We aimed to evaluate differences in complications of support pessaries for vaginal prolapse in postmenopausal women, with and without vaginal estrogen use. STUDY DESIGN: We prospectively assessed postmenopausal women attending the urogynaecology clinic for a pessary change. We asked them about the level of discomfort during pessary change (visual analogue scale for pain), discharge, bleeding and infection. Ethics approval was not required as this was a service evaluation project. Statistical analysis for relative risk was performed, including sub-group analysis for 'ring pessary' and 'non-ring group' (Shelf, Gellhorn, Shaatz). RESULTS: Between July 2013 and December 2014, we assessed 120 postmenopausal women using support pessaries for prolapse. The mean age was 70 years; 45% of the patients used vaginal estrogen. There were no statistically significant differences in complications with or without vaginal estrogen use, although the trend was higher amongst non-users. The 'non-ring' sub-group not using vaginal estrogen had a higher risk of vaginal ulceration, bleeding and discharge. CONCLUSION: Postmenopausal women may have lesser complications when using vaginal estrogen with a support pessary for prolapse, particularly with pessaries other than the ring. An adequately powered randomised controlled trial is needed to assess conclusively whether vaginal estrogen enhances comfort and reduces complications of support pessaries for prolapse.

Dantrolene an unusual option for detrusor overactivity: observations of a patient with cerebral palsy.

We report a case of a 49-year-old female with cerebral palsy with spastic tri-plegia and lumbar spondyolisthesis diagnosed to have overactive neurogenic bladder, which improved on treatment with Dantrolene along with antimuscarinics. She was initially treated with antimuscarinics both transdermal and oral simultaneously and later received intravesical OnaBotulinum toxinA. Following lumbar spine fixation for spondylolisthesis, her bowel and bladder function deteriorated and she was commenced on Dantrolene for her spasticity, along with being on Oxybutinin and Mirabegron. This significantly improved her symptoms. Overactive bladder symptoms are a common manifestation in cases of CP. In refractory cases where antimuscarinics and intravesical botulinum toxin therapy have failed, a combination of Dantrolene with antimuscarinics and/or beta 3 receptor agonists may prove to be beneficial. While on therapy, regular monitoring of liver functions is required to promptly diagnose and treat hepatotoxicity.

Urogynecological effects of menopause.

The menopause signifies a period after significant hormonal change that affects all estrogen-sensitive tissues. This change may result in symptoms affecting any part of the urogenital system. These changes can significantly affect women's health and quality of life. The menopause is associated with lower urinary tract symptoms, vulvovaginal symptoms and pelvic organ prolapse. In this article, we have aimed to describe the symptomatology along with pathophysiology of the effects of menopause on urogynecological problems affecting women's health. Other factors apart from menopause add to these symptoms, like parity, mode of delivery, obesity, smoking and poor psychological health.