Resurgence of Autologous Fascial Slings in a Challenging Climate for Sling Surgery: A 20-Year Review of Comparative Data.

Importance: Since the US Food and Drug Administration's 2016 ban of transvaginal mesh use in vaginal prolapse surgery, there has been growing public scrutiny over the use of synthetic mesh slings (SSs) for the surgical management of female stress urinary incontinence (SUI). Although long considered the mainstay of current practice, interest in biological alternatives has grown. Objectives: This article reviews the last 20 years of data comparing the success of autologous fascial slings (AFSs) and SSs in the treatment of female SUI. Evidence Acquisition: We reviewed the literature for randomized controlled trials comparing autologous pubovaginal sling and SS for the primary surgical treatment of female SUI using several search engines and databases between January 1, 2000, and March 31, 2020. Study Appraisal and Synthesis Methods: Data were retrieved and compared across studies. Trials were evaluated for study setting, type, population characteristics, sample size, success definition and rate, recurrence rate, operative time, length of hospital stay, complications, and quality of life. Results: Of the 1382 articles reviewed, 8 met eligibility criteria, representing 6 distinct cohorts and 726 subjects. Synthetic slings available for review were either tension-free vaginal tape (TVT) or minisling. The vast majority of studies demonstrated similar short- and long-term success rates of AFS and SS procedures utilizing a range of outcome measures. Both AFS and TVT sling had low recurrence rates in short- and long-term follow-up. However, AFS had significantly longer operative time, and longer hospital stay. Bladder perforation, on the other hand, occurred more commonly in TVT sling. Health-related quality-of-life scores, including sexual function, were similar between groups. Conclusions: Autologous fascial sling and SS are both highly effective surgical procedures for the treatment of female SUI. Although success rates are comparable, AFS is associated with less favorable operative measures. Relevance: This review supports the effectiveness of AFS in treating female SUI as concerns over the use of synthetic materials in vaginal surgery rise. However, clinicians must weigh the risks conferred by this nonsynthetic alternative.

The Role of Pelvic Floor Muscle Training in the Conservative and Surgical Management of Female Stress Urinary Incontinence: Does the Strength of the Pelvic Floor Muscles Matter?

The purpose of this review is to provide an in-depth overview of the role of pelvic floor muscle (PFM) training in the management of stress urinary incontinence (SUI). The definition, epidemiology, and pathogenesis of SUI are described. We review the anatomy of the PFM and the importance of PFM strength in maintaining urinary continence and establishing normal voiding function. A brief description of the surgical options currently available for SUI and the existing data regarding the role of perioperative PFM training for SUI are included. Critical research questions to better evaluate and assess PFM training during the perioperative period are proposed. Promising novel approaches in the treatment of SUI are also presented. This review is useful for physiatrists, urogynecologists, female urologists, and nurse practitioners who specialize in the management and treatment of women with SUI. LEVEL OF EVIDENCE: IV.

Urinary Incontinence in Pregnant Young Women and Adolescents: An Unrecognized At-Risk Group.

OBJECTIVES: The aims of this study were to determine the prevalence of urinary incontinence (UI) in pregnant young women and adolescents, characterize UI subtype, and identify characteristics associated with UI. METHODS: This was a cross-sectional study of pregnant females aged 25 years or below, presenting for routine obstetrical care at a New York City community hospital. Subjects were stratified into 2 groups: adolescents (age, ≤19 years) and young adults (age, >19 years). Demographic and obstetric data were collected. The 3 Incontinence Questions questionnaire was used to screen and evaluate UI symptoms. RESULTS: A total of 98 young females with a mean age of 20.3 ± 2.6 years were enrolled. Most participants were nulliparous (64%). Of parous women, route of previous obstetric delivery was primarily vaginal (83%). Mean gestational age at recruitment was 34.5 ± 7.5 weeks. The prevalence of UI was 52%. Urinary incontinence was associated with the following conditions: strenuous activity, 73%; urinary urgency, 67%; and absence of either, 20%. However, the most predominant UI subtype was with strenuous activity (63%). There was no statistical difference detected in demographic characteristics (such as age, parity, mode of delivery, race, education, and trimester of pregnancy) between continent and incontinent pregnant females (P > 0.18). No differences were appreciated between pregnant adolescents and young adult females with UI (P > 0.18). CONCLUSIONS: Urinary incontinence was present in 52% of pregnant females aged 25 years or below. By age group, approximately 50% of both adolescents and young adults reported UI during pregnancy. Continent and incontinent patients did not seem to differ demographically. Our study highlights the extent of UI in this segment of the population. This data may support the need for services targeting UI prevention and early intervention in this newly identified at-risk group.

Sexual activity and function in women with and without pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: We describe differences in sexual activity and function in women with and without pelvic floor disorders (PFDs). METHODS: Heterosexual women ≥40 years of age who presented to either urogynecology or general gynecology clinics at 11 clinical sites were recruited. Women were asked if they were sexually active with a male partner. Validated questionnaires and Pelvic Organ Prolapse Quantification (POP-Q) examinations assessed urinary incontinence (UI), fecal incontinence (FI), and/or pelvic organ prolapse (POP). Sexual activity and function was measured by the Female Sexual Function Index (FSFI). Student's t test was used to assess continuous variables; categorical variables were assessed with Fisher's exact test and logistic regression. Univariate and multivariate analyses were used to assess the impact of pelvic floor disorders (PFDs) on FSFI total and domain scores. RESULTS: Five hundred and five women met eligibility requirements and gave consent for participation. Women with and without PFDs did not differ in race, body mass index (BMI), comorbid medical conditions, or hormone use. Women with PFDs were slightly older than women without PFDs (55.6 + 10.8 vs. 51.6 + 8.3 years, P <0.001); all analyses were controlled for age. Women with PFDs were as likely to be sexually active as women without PFDs (61.6 vs. 75.5 %, P = 0.09). There was no difference in total FSFI scores between cohorts (23.2 + 8.5 vs. 24.4 + 9.2, P = 0.23) or FSFI domain scores (all P = NS). CONCLUSION: Rates of sexual activity and function are not different between women with and without PFDs.

A randomized clinical trial of the impact of local estrogen on postoperative tissue quality after vaginal reconstructive surgery.

OBJECTIVE: To evaluate the use and effect of early administration of vaginal estrogen via a continuous low-dose estradiol vaginal ring placed immediately after pelvic reconstructive surgery. METHODS: This was a randomized controlled trial of 65 postmenopausal women undergoing vaginal reconstructive surgery. The subjects were randomly assigned to receive an estradiol-releasing vaginal ring, placebo vaginal ring, or control without vaginal ring for 12 weeks immediately after vaginal reconstructive surgery. The primary outcome was tissue quality based on vaginal maturation 3 months postoperatively. Secondary outcome measures were subjective and objective signs of atrophy; vaginal pH; the presence of granulation tissue, microscopic inflammation, and major healing abnormalities; and the ability to tolerate an intravaginal ring. RESULTS: At 12 weeks, the estradiol ring group had a significantly improved maturation value (P<0.01) and objective atrophy assessment (P<0.01) compared with the placebo ring and control arms. Granulation tissue was increased in the placebo ring arm (P<0.01). Subjective atrophy scores did not differ among the groups (P=0.39). CONCLUSIONS: Early administration of vaginal estrogen after vaginal surgery via an estradiol-releasing ring is feasible and results in improved markers of tissue quality postoperatively compared to placebo and controls.

"Eyeball" POP-Q examination: shortcut or valid assessment tool?

INTRODUCTION AND HYPOTHESIS: The objective of this study was to compare the results of the Pelvic Organ Prolapse Quantification (POP-Q) examination by visual estimation to measurement. METHODS: Women with pelvic organ prolapse underwent both "eyeball"/estimated and measured POP-Q examinations by two trained examiners in a randomized order. POP-Q points and stage were analyzed using the paired t test, chi-square, Pearson's correlation, and kappa statistics. RESULTS: Fifty subjects had a mean age of 60, mean BMI 27.8, and median parity of 2. The POP-Q stages by the measured technique were 18% (9/50) stage 1, 38% (19/50) stage 2, 44% (22/50) stage 3, and 0% (0/50) stage 4. The POP-Q stages based on estimation and measurement were highly associated (p < 0.05). Individual points did not differ significantly between the techniques and did not differ significantly between examiners (all p > 0.05). CONCLUSION: Among examiners who routinely perform POP-Q examinations, there is no significant difference between "eyeball"/estimated and measured POP-Q values and stage.

Measurement of pelvic floor muscular strength with the Colpexin pull test: a comparative study.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to compare the Colpexin pull test (CPT) with the Oxford muscle grading scale (OMGS) in assessing pelvic floor muscle strength. METHODS: In phase 1, 15 asymptomatic women underwent OMGS and CPT using three different spheres to select the ideal size. CPT values as well as patient/examiner comfort and ease of CPT performance were recorded. In phase 2, 30 women with stress urinary incontinence underwent CPT and OMGS by two examiners during two separate sessions. Statistical analysis was performed. RESULTS: In phase 1, the 36-mm sphere was selected based on resting (p < 0.001), contraction CPT (p < 0.001), patient ease (p = 0.018), patient comfort (p = 0.004), and examiner comfort (p < 0.001). In phase 2, there was good intra-rater and inter-rater agreement in maximum CPT. Both tests were positively correlated (r = 0.50, p < 0.001). CONCLUSION: CPT is an objective measure of pelvic floor strength and provides consistent, reproducible results.

Does vaginal size impact sexual activity and function?

INTRODUCTION AND HYPOTHESIS: This study seeks to determine if total vaginal length (TVL) or genital hiatus (GH) impact sexual activity and function. METHODS: Heterosexual women >or= 40 years were recruited from urogynecology and gynecology offices. TVL and GH were assessed using the Pelvic Organ Prolapse Quantification exam. Women completed the Female Sexual Function Index (FSFI) and were dichotomized into either normal function (FSFI total > 26) or sexual dysfunction (FSFI