Diagnostic test accuracy of magnetic resonance imaging and pelvic floor ultrasound for diagnosis of levator ani muscle avulsion.

OBJECTIVE: To estimate the diagnostic test accuracy of magnetic resonance imaging (MRI) and pelvic floor ultrasound for levator ani muscle (LAM) avulsion in a general parous population, with view to establishing if ultrasound could substitute for MRI to diagnose LAM avulsion. METHODS: This was a cross-sectional study of 135 women 4 years after their first delivery. Signs and symptoms of pelvic floor dysfunction were assessed using validated methods. All women underwent four-dimensional transperineal ultrasound (TPUS), three-dimensional endovaginal ultrasound (EVUS) and MRI. Images were acquired at rest, on pelvic floor muscle contraction (PFMC) and on maximum Valsalva maneuver, and analyzed by two blinded observers. Predefined cut-off values were used to diagnose LAM avulsion. In the absence of a reference standard, latent class analysis (LCA) was used to establish diagnostic test characteristics for LAM avulsion as the primary outcome measure. Secondary outcomes were kappa (κ) agreement between imaging techniques, intraclass correlation coefficients (ICC) for hiatal measurements at rest, on PFMC and on maximum Valsalva maneuver, and the association of LAM avulsion with signs and symptoms of pelvic floor dysfunction. RESULTS: The prevalence of LAM avulsion was 23.0% for MRI, 11.1% for TPUS and 17.8% for EVUS. The prevalence of LAM avulsion using LCA was 15.7%. The sensitivity for LAM avulsion of TPUS (71% (95% CI, 50-90%)) and EVUS (91% (95% CI, 74-100%)) was lower than that of MRI (100% (95% CI, 84-100%)). The specificity of TPUS (100% (95% CI, 97-100%)) and EVUS (95% (95% CI, 91-99%)) was higher than that of MRI (91% (95% CI, 85-97%)). MRI and EVUS had high predictive values for the assessment of major LAM avulsion (positive predictive value (PPV), 95% and negative predictive value (NPV), 100%; PPV, 100% and NPV, 98%, respectively), while TPUS had high predictive values for minor LAM avulsion (PPV, 100% and NPV, 95%). Major LAM avulsion on MRI and EVUS was associated with anterior vaginal wall prolapse, which was not found for TPUS. The agreement in the diagnosis of LAM avulsion (κ, 0.69) and hiatal measurements (ICC, 0.60-0.81) was highest between MRI and EVUS. CONCLUSIONS: Pelvic floor ultrasound can be implemented as a triage test to assess parous women for LAM avulsion because of its high specificity. Ultrasound cannot substitute for MRI because of its lower sensitivity. The predictive ability of ultrasound is moderate for the presence, and very good for the absence, of LAM avulsion. A positive test should be confirmed by a different observer or imaging technique. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

The role of obesity on urinary incontinence and anal incontinence in women: a review.

Obesity prevalence is increasing worldwide, with significant healthcare implications. We searched PubMed/MEDLINE, Embase and the Cochrane Library for articles registered until June 2020 to explore the relationship between obesity and urinary (UI) and anal incontinence (AI). Obesity is associated with low-grade, systemic inflammation and proinflammatory cytokine release, producing reactive oxygen species and oxidative stress. This alters collagen metabolism and, in combination with increased intra-abdominal pressure, contributes to the development of UI. Whereas in AI, stool consistency may be a factor. Weight loss can reduce UI and should be a management focus; however, the effect of weight loss on AI is less clear.

3D-Volume Rendering of the Pelvis with Emphasis on Paraurethral Structures Based on MRI Scans and Comparisons between 3D Slicer and OsiriX®.

The feasibility of rendering three dimensional (3D) pelvic models of vaginal, urethral and paraurethral lesions from 2D MRI has been demonstrated previously. To quantitatively compare 3D models using two different image processing applications: 3D Slicer and OsiriX. Secondary analysis and processing of five MRI scan based image sets from female patients aged 29-43 years old with vaginal or paraurethral lesions. Cross sectional image sets were used to create 3D models of the pelvic structures with 3D Slicer and OsiriX image processing applications. The linear dimensions of the models created using the two different methods were compared using Bland-Altman plots. The comparisons demonstrated good agreement between measurements from the two applications. The two data sets obtained from different image processing methods demonstrated good agreement. Both 3D Slicer and OsiriX can be used interchangeably and produce almost similar results. The clinical role of this investigation modality remains to be further evaluated.

A systematic review on reported outcomes and outcome measures in female idiopathic chronic pelvic pain for the development of a core outcome set.

BACKGROUND: A core outcome set (COS) is required to address inconsistencies in outcome reporting in chronic pelvic pain (CPP) trials. OBJECTIVES: Evaluation of reported outcomes and selected outcome measures in CPP trials by producing a comprehensive inventory to inform a COS. SEARCH STRATEGY: Systematic review of randomised controlled trials (RCTs) identified from Cochrane Central Register of Controlled Trials (CENTRAL), Embase and MEDLINE databases. SELECTION CRITERIA: RCTs assessing efficacy and safety of medical, surgical and psychological interventions for women with idiopathic CPP. DATA COLLECTION AND ANALYSIS: Two independent researchers extracted outcomes and outcome measures. Similar outcomes were grouped and classified into domains to produce a structured inventory. MAIN RESULTS: Twenty-four trials were identified including 136 reported outcomes and outcome measures. Rates of reporting outcomes varied (4-100%) and pelvic pain was the most frequently reported outcome (100%). All trials reported the pain domain; however, only half reported quality of life, clinical effectiveness and adverse events. No differences in outcome reporting were observed in five high-quality trials (21%). Univariate analysis demonstrated an association between quality of outcome reporting and methodological quality of studies (rs  = 0.407, P = 0.048). CONCLUSION: There is wide variation in reported outcomes and applied outcome measures in CPP trials. While a COS is being developed and implemented, we propose the interim use of commonly reported outcomes in each domain: pain (pelvic pain, dyspareunia, dysmenorrhoea), life impact (quality of life, emotional functioning, physical functioning), clinical effectiveness (efficacy, satisfaction, cost effectiveness, return to daily activities) and adverse events (surgical, perioperative observations, nonsurgical). TWEETABLE ABSTRACT: There is significant variation in outcome reporting in CPP trials. Our systematic review forms the basis for the development of a core outcome set.

A systematic review on outcome reporting in randomised controlled trials on surgical interventions for female stress urinary incontinence: a call to develop a core outcome set.

BACKGROUND: Several meta-analyses have identified methodological limitations in female stress urinary incontinence (SUI) trials, precluding the synthesis of primary studies and high-quality evidence. OBJECTIVES: Evaluation of outcome measure selection and outcome reporting in randomised controlled trials (RCTs) on surgery for SUI. SEARCH STRATEGY: Systematic review of RCTs identified from bibliographical databases, including Medline, Cochrane, and EMBASE. SELECTION CRITERIA: Randomised controlled trials evaluating the efficacy and safety of surgical interventions for the management of female SUI. DATA COLLECTION AND ANALYSIS: Two researchers independently assessed the included studies and documented outcomes. MAIN RESULTS: Overall, 108 studies were identified that included 422 reported outcomes and 119 outcome measures. The three most common outcomes were cure rates (87 studies), quality of life (85 studies), and overactive bladder (78 studies). The median methodological quality rating was 3 (range 0-3) and the outcome reporting quality rating was 3 (range 0-5). Multinomial logistic regression analysis revealed that the methodological quality and use of validated questionnaire were significant predictors of the quality of outcome reporting (ß = 0.538, P < 0.001; ß = 0.218, P = 0.011, respectively). CONCLUSIONS: Outcome reporting in SUI trials is highly variable. Until a core outcome set is developed and implemented, we propose an interim use of three commonly reported outcomes in each domain (treatment success rate - complete cure, partial improvement, or failure of response; urodynamic evaluation outcomes - overactive bladder (OAB), voiding dysfunction, and urodynamic stress incontinence; patient-reported outcomes - quality of life, sexual dysfunction, and patient satisfaction) with the use of validated questionnaires for patient-reported outcomes and subjective success rates. Complications should be also explicitly and comprehensively reported using validated outcome measures. TWEETABLE ABSTRACT: There is significant variation in outcome reporting in SUI trials. Our systematic review findings aim to form the basis for the development of a core outcome set.

Do we need a core outcome set for childbirth perineal trauma research? A systematic review of outcome reporting in randomised trials evaluating the management of childbirth trauma.

BACKGROUND: Selecting appropriate outcomes to reflect both beneficial and harmful effects is a critical step in designing childbirth trauma trials. OBJECTIVE: To evaluate the outcomes and outcome measures reported in randomised controlled trials evaluating interventions for childbirth trauma. SEARCH STRATEGY: Randomised trials were identified by searching bibliographical databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. SELECTION CRITERIA: Randomised trials evaluating the efficacy and safety of different techniques in the management of perineal lacerations. DATA COLLECTION AND ANALYSIS: Two researchers independently assessed studies for inclusion, evaluated methodological quality, and extracted the relevant data. Spearman's ρ correlation and multivariate linear regression analysis using the backward stepwise model were used for analysis. MAIN RESULTS: Forty-eight randomised trials, reporting data from 20 308 women, were included. Seventeen different interventions were evaluated. Included trials reported 77 different outcomes and 50 different outcome measures. Commonly reported outcomes included pain (34 trials; 70%), wound healing (20 trials; 42%), and anorectal dysfunction (16 trials, 33%). In the multivariate analysis, no relationship was demonstrated between the quality of outcome reporting and year of publication (P = 0.31), journal impact factor (P = 0.49), and methodological quality (P = 0.13). CONCLUSION: Outcome reporting in childbirth trauma research is heterogeneous. Developing, disseminating, and implementing a core outcome set in future childbirth trauma research could help address these issues. TWEETABLE ABSTRACT: Developing @coreoutcomes for childbirth trauma research could help to reduce #research waste.

Platelet rich plasma as a minimally invasive approach to uterine prolapse.

Pelvic organ prolapse (POP) is a major health problem that affects many women with potentially severe physical and psychological impact as well as impact on their daily activities, and quality of life. Several surgical techniques have been proposed for the treatment of POP. The FDA has published documents that refer to concerns about the use of synthetic meshes for the treatment of prolapse, in view of the severe complications that may occur. These led to hesitancy in use of these meshes and partial increase in use of other biological grafts such as allografts and xenografts. Although there seems to be an increasing tendency to use grafts in pelvic floor reconstructive procedures due to lower risks of erosion than synthetic meshes, there are inconclusive data to support the routine use of biological grafts in pelvic organ prolapse treatment. In light of these observations new strategies are needed for the treatment of prolapse. Platelet rich plasma (PRP) is extremely rich in growth factors and cytokines, which regulate tissue reconstruction and has been previously used in orthopaedics and plastic surgery. To date, however, it has never been used in urogynaecology and there is no evidence to support or oppose its use in women who suffer from POP, due to uterine ligament defects. PRP is a relatively inexpensive biological material and easily produced directly from patients' blood and is, thus, superior to synthetic materials in terms of potential adverse effects such as foreign body reaction. In the present article we summarize the existing evidence, which supports the conduct of animal experimental and clinical studies to elucidate the potential role of PRP in treating POP by restoring the anatomy and function of ligament support.

The impact of subcutaneous tissue suturing at caesarean section on wound complications: a meta-analysis.

BACKGROUND: Caesarean wound complications are frequently observed in everyday practice. OBJECTIVES: To study whether subcutaneous tissue closure following caesarean section results in decreased wound complications. SEARCH STRATEGY: We systematically searched Medline (1966-2016), Scopus (2004-2016), ClinicalTrials.gov (2008-2016) and Cochrane Central Register of Controlled Trials CENTRAL (1999-2016) databases together with reference lists from included studies. SELECTION CRITERIA: Randomised and quasi-randomised trials that investigated the impact of subcutaneous tissue suturing on wound complications following caesarean section were held eligible for inclusion. Retrospective studies and prospective nonrandomised studies were excluded from the present meta-analysis. DATA COLLECTION AND ANALYSIS: The methodological quality of studies was assessed with the Jadad scale. Statistical meta-analysis was performed with the RevMan 5.3 software. MAIN RESULTS: Ten studies were finally included in our meta-analysis, which involved 3696 women delivered by caesarean section. Re-approximation of the subcutaneous tissue significantly reduced the odds of developing any type of wound complication [3811 women, random effects model (REM), odds ratio (OR) 0.66, 95% CI 0.47-0.93]. The incidence of seroma was also decreased (1979 women, REM, OR 0.53, 95% CI 0.33-0.84). On the other hand, the incidence of haematoma remained unaffected by subcutaneous closure (1663 women, REM, OR 0.74, 95% CI 0.22-2.42) as well as the likelihood of developing a wound infection (1971 women, REM, OR 0.99, 95% CI 0.70-1.41). CONCLUSIONS: The results of our meta-analysis suggest that subcutaneous tissue closure may benefit women undergoing caesarean section. Current data in women with high body mass index remain very limited; hence, definitive conclusions are precluded for this specific group. TWEETABLE ABSTRACT: Subcutaneous tissue closure may benefit women undergoing caesarean section.

Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review.

BACKGROUND: Uterine-sparing surgical interventions have long been practiced as an alternative to hysterectomy in the management of severe postpartum haemorrhage (PPH); however, the risks of impairment of subsequent fertility from such procedures are unclear. OBJECTIVE: To evaluate the menstrual and fertility outcomes following radiological or conservative surgical interventions for severe PPH. SEARCH STRATEGY: A systematic review of English and non-English articles using the Cochrane Library 2012, PubMed (1950-2012), Embase (1980-2012), and the National Research Register. The keywords used for our search included 'fertility', 'reproductive outcome', 'postpartum haemorrhage', 'embolisation', 'hypogastric artery ligation', 'B-Lynch suture', 'stepwise uterine devascularisation', 'tamponade', and 'uterine compression sutures'. SELECTION CRITERIA: Studies including human female subjects with at least five cases. DATA COLLECTION AND ANALYSIS: Independent extraction of articles by two authors using predefined data fields, including study quality indicators. MAIN RESULTS: We identified 402 publications and after exclusions, 28 studies were included in the systematic review. Seventeen studies (675 women) reported on the fertility outcomes after uterine artery embolisation, five studies (195 women) reported on the fertility outcomes after uterine devascularisation, and six studies (125 women) reported on the fertility outcomes following uterine compression sutures. Overall, 553 out of 606 (91.25%) women resumed menstruation within 6 months of delivery. One hundred and eighty-three out of 235 (77.87%) women who desired another pregnancy achieved conception. AUTHOR'S CONCLUSIONS: Uterine-sparing radiological and surgical techniques for the management of severe PPH do not appear to adversely affect the menstrual and fertility outcomes in most women; however, the number of studies and the quality of the available evidence is of concern.

Perineal trauma in women undergoing vaginal delivery following intra-uterine fetal demise: a case-control analysis.

INTRODUCTION AND HYPOTHESIS: This study aimed to evaluate any differences in the incidence of perineal trauma in women undergoing vaginal delivery following intrauterine fetal death (IUFD) versus live-births. This information would be of interest in evaluating the possible effect of fetal demise on the mechanism of labour in the second stage and thus may provide invaluable insights to contribute to our understanding of the impact of fetal tone on the mechanics of labour and delivery. METHODS: 323 women who delivered vaginally following IUFD were matched with 1,000 women with a live-birth for age, parity, gestation and birth weight. Women undergoing assisted vaginal delivery and/or episiotomy were excluded. RESULTS: Women with an IUFD had a significantly lower risk of perineal trauma overall (relative risk 0.16) as well as a lower risk of obstetric anal sphincter injury specifically (RR 0.12). CONCLUSIONS: Women delivering vaginally after IUFD have a lower incidence of perineal trauma compared with women delivering a live infant. This may be due to differences in biomechanics following an IUFD.

The effect of lead intoxication on endocrine functions.

Studies on the effects of lead on the endocrine system are mainly based on occupationally lead-exposed workers and experimental animal models. Although evidence is conflicting, it has been reported that accumulation of lead affects the majority of the endocrine glands. In particular, it appears to have an effect on the hypothalamic-pituitary axis causing blunted TSH, GH, and FSH/LH responses to TRH, GHRH, and GnRH stimulation, respectively. Suppressed GH release has been reported, probably caused by reduced synthesis of GHRH, inhibition of GHRH release or reduced somatotrope responsiveness. Higher levels of PRL in lead intoxication have been reported. In short-term lead-exposed individuals, high LH and FSH levels are usually associated to normal testosterone concentrations, whereas in long-term exposed individuals' low testosterone levels do not induce high LH and FSH concentrations. These findings suggest that lead initially causes some subclinical testicular damage, followed by hypothalamic or pituitary disturbance when longer periods of exposure take place. Similarly, lead accumulates in granulosa cells of the ovary, causing delays in growth and pubertal development and reduced fertility in females. In the parenchyma of adrenals histological and cytological changes are demonstrated, causing changes in plasma basal and stress-mediated corticosterone concentrations and reduced cytosolic and nuclear glucocorticoid receptor binding. Thyroid hormone kinetics are also affected. Central defect of the thyroid axis or an alteration in T4 metabolism or binding to proteins may be involved in derangements in thyroid hormone action. Lead toxicity involves alterations on calcitropic hormones' homeostasis, which increase the risk of skeletal disorders.

sRANKL/osteoprotegerin complex and biochemical markers in a cohort of male and female hemodialysis patients.

OBJECTIVE: The processes involved in bone remodeling are under the control of a multitude of systemic and local factors. Receptor activator of nuclear factor-kappaB ligand (RANKL)/osteoprotegerin (OPG) complex seems to be one of the major modulators of bone remodeling. In chronic renal failure, the cytokine systems involved in the regulation of bone turnover may be influenced, and are therefore likely to contribute to the pathogenesis of renal bone disease. The aim of the present study was the evaluation of RANKL/OPG complex in concert with other biochemical parameters in hemodialysis (HD) patients and the investigation of possible correlations between the serum levels of its components and several clinical parameters of these patients. METHODS: We measured serum levels of intact PTH (iPTH), total serum RANKL (sRANKL), osteoprotegerin (OPG), alkaline phosphatase, osteocalcin (OC), and tartrate-resistant acid phosphatase (TRAP) in 104 HD patients and in 40 healthy controls. RESULTS: The average serum OPG level was significantly higher, whereas the average serum concentration of RANKL was nonsignificantly lower in patients on HD therapy than in age-matched healthy controls. Consequently, the mean sRANKL/OPG ratio was significantly lower in patients. Among HD patients, serum level of OPG increased significantly with aging and with a longer duration of hemodialysis. RANKL levels were inversely correlated with age nonsignificantly in the whole group of patients and significantly in the female subgroup (r=-0.322, p=0.035), whereas RANKL/OPG ratio declined significantly with age in the entire cohort of patients (r=-0.259, p=0.008). In addition, iPTH, OC, TRAP were significantly higher in female, whereas RANKL/OPG ratio was significantly higher in male than female patients. CONCLUSIONS: Lower values of sRANKL/OPG ratio in HD patients, as well as the age and duration of HD dependent increase of serum OPG and the age-dependent decrease of sRANKL concentration especially in women cannot be explained by the elimination of renal clearance only. Alterations in sRANKL/OPG ratio might reflect a compensatory mechanism to modulate bone remodeling in these patients.