Cutting a mediolateral episiotomy at the correct angle: evaluation of a new device, the Episcissors-60.

BACKGROUND: Anal incontinence is nine times more prevalent in women than in men due to obstetric anal sphincter injury (OASI). OASI is linked to midline episiotomies and mediolateral episiotomies with post-delivery angles of <30 and >60 degrees. Studies show that doctors and midwives are unable to correctly "eyeball" the safe angle required due to perineal stretching by the fetal head at crowning. A new scissor instrument (Episcissors-60) was devised to allow cutting a mediolateral episiotomy at a fixed angle of 60 degrees from the perineal midline. METHODS: Scissors with a marker guide limb pointing towards the anus were devised, ensuring an angle of 60 degrees between the scissor blades and the guide limb. This device was initially tested in models. Post-delivery angles were recorded on transparencies and analyzed by an author blinded to clinical details. Accoucheurs were asked to rate the ease of use on a 5-point scale. RESULTS: Of the 17 women, 14 delivered with ventouse, two with forceps, and one with sequential ventouse-forceps. Indications for instrumental delivery were suboptimal cardiotocogram and/or prolonged second stage of labor. Mean birth weight was 3.41 (2.92-4.12) kg. A mean post-delivery angle of 42.4±7 (range 30-60, median 43) degrees (95% confidence interval 38.8-46) was achieved with the Episcissors-60 instrument. Eighty-eight percent of clinicians agreed or strongly agreed that the scissors were easy to use. CONCLUSION: The Episcissors-60 delivered a consistent post-delivery angle of 43 degrees. They could replace "eyeballing" when performing mediolateral episiotomies and form part of a preventative strategy to reduce OASI.

Management of complex pelvic floor disorders in a multidisciplinary pelvic floor clinic.

OBJECTIVE: To identify symptom clusters, management strategies and survey patient satisfaction in our combined multidisciplinary pelvic floor clinic (PFC). METHOD: Retrospective cohort study, patient satisfaction questionnaire. SAMPLE: Secondary and tertiary referrals with complex pelvic floor disorders. MAIN OUTCOME MEASURES: symptom clusters and treatment received; patient satisfaction. RESULTS: A total of 113 new cases over a 3-year period. There were two main symptom clusters: (i) obstructed defaecation with rectoceles (n = 55); of these, 23 had abdominal sacrocolpopexy with rectopexy, six had transvaginal rectocele repairs; and (ii) of the 33 with double incontinence, 10 had anal sphincter repairs, five had tension-free vaginal tapes and two had colposuspensions. Patient satisfaction audit: 73% found the care to be excellent/good, 12% satisfactory and 6% unsatisfactory. CONCLUSION: Combined PFCs led to a more pragmatic approach in treating patients' symptoms. Combined surgery was undertaken in one-fourth of patients and is associated with cost savings and a single recuperation period. Overall, patients rated this service very highly.

Pelvic floor dysfunction management practice patterns: a survey of members of the International Urogynecological Association.

The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.

Grades of intrinsic sphincteric deficiency (ISD) associated with female stress urinary incontinence.

Intrinsic urethral sphincter deficiency (ISD) is a clinical entity that should be suspected in women with stress urinary incontinence. If it is not diagnosed prior to surgery, it poses a significant risk factor for repair failure. We propose a classification of ISD based on videofluorourodynamic (VFUD) and abdominal leak-point pressures. One hundred female patients with stress urinary incontinence due to ISD were included in this study. History and physical examination were performed on all patients. Each patient underwent a standard VFUD study with abdominal leak-point pressure (ALPP) measurement. ISD is classified into subtypes according to VFUDS and ALPP. The findings were then correlated with the clinical presentation, etiology and proposed management. Three types of ISD/SUI were identified. ISD-A, subtle/urodynamic, was present in 32 patients (32%). It is most difficult to diagnose because radiologically the bladder neck is not open at rest, and it is only diagnosed by VFUD. The abdominal leak-point pressure was less than 12 cmH2O. ISD-B was present in 45 patients (45%). This is characterized by a beak-shaped open bladder neck at rest. The abdominal leak-point pressure was less than 90 cmH2O. ISD-C was present in 14 patients (14%). It is characterized by an open, fixed non-functioning urethra (pipe-stem) with high position of the bladder neck. The abdominal leak-point pressure was less than 70 cmH2O. All the three subtypes had proximal urethral closure pressure (PCUP) less than 10 cmH2O. Based on these data, the treatment options may vary from one subtype to another. For ISD-A, initial treatment was medical, with collagen injection being used for the failed cases. For ISD-B a modified pubovaginal sling was used, as it corrects the ISD and the urethral hypermobility at the same time. For ISD-C, urethrolysis and takedown of the previous suspension was required before using a sling. Collagen injections were used in selected cases. This classification identifies different subgroups of ISD, which is important in the diagnosis and management of this condition.

Nonautologous sling materials.

This article provides a comprehensive and updated review of the current nonautologous sling materials available for treatment of stress urinary incontinence. The various materials are described, relevant clinical studies are discussed, and newer materials are outlined. Complications arising from use of different materials also are described.