Female Urinary Incontinence: Frequency, Risk Factors, and Impact on the Quality of Life of Pregnant Pakistani Women.

Objectives: To determine the frequency and associated risk factors of urinary incontinence (UI), and its effect on the quality of life (QOL) of pregnant Pakistani women. Methods: This was a cross-sectional study of 309 pregnant women, 16-40 weeks gestation, age 18- 45 years, at the Aga Khan University Hospital Karachi, between August 2019 and February 2020. Data were obtained using the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short form (ICIQ-UI-SF). Results: The frequency of UI was 63.1%. Stress UI was the commonest type (53.0%) followed by urgency (17.5%) and mixed UI (11.7%). In majority of women, it occurred in small amounts, once a week with a very severe impact on QoL in 24.91% of women, affecting sexual relation the most. Risk factors for UI in pregnancy were age > 35 years (p < 0.02), gestation > 37 weeks (p< 0.00), higher body mass index and family history of UI (p< 0.00), previous instrumental vaginal delivery (P < 0.002), cough, constipation and strenuous job (p< 0.00), and lack of pelvic floor muscle exercises (p <0.03). Conclusions: UI is a common problem in pregnant women in Pakistan. It affects sexual functions the most, with a severe impact on the QOL, however, it commonly remains unreported. Thus the health care providers need to enquire all pregnant women on this issue, especially those at risk, and educate them on the available management options.

Vaginal Reconstruction in Patients with vaginal agenesis: Options and Outcome: A single-center experience.

Objectives: To assess the postoperative functional, anatomical outcome and complications of various surgical procedures of vaginoplasty performed for patients with vaginal agenesis at our institution. Methods: This was a cross-sectional study of 14 patients (age range 17-40 years), who underwent vaginoplasty at the Aga Khan University Hospital, Karachi, Pakistan between January 2008 to December 2018. We aimed to assess the anatomical outcomes in terms of vaginal depth, axis and functional outcome as painless and satisfactory vaginal intercourse. Results: The mean age and mean body mass index (BMI) of the cases were 26.8 ± 8.1 years and 27.7143 ± 4.6 respectively. All were phenotypically female, with only two cases of XY genotype. Two patients were married on presentation. On evaluation, four cases had Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, three had androgen insensitivity syndrome (AIS), one case had congenital adrenal hyperplasia and six cases did not fit into any diagnosis. Associated renal anomalies were diagnosed in 14.3% of cases. The performed procedures were; Singaporean flap vaginoplasty (in four patients), Lee's, modified McIndoe and pull-through vaginoplasty (in three each patients), and Davydov vaginoplasty (in one patient). One patient was complicated by intraoperative bladder injury (p<0.63) and two cases by vaginal stenosis (p<0.43). The mean operative time was 120 minutes and the mean estimated blood loss was 200mls. Postoperatively, the vaginal length varied from 6-10 cm with a normal vaginal axis and satisfactory sexual activity. Conclusions: Vaginal agenesis is associated with several sexual disorders and despite the various surgical options available, the best procedure in terms of fewer complications and best surgical outcome is yet to be determined.

Vaginal Leiomyoma Presenting as Pelvic Organ Prolapse in Pregnancy.

Vaginal leiomyomas are extremely rare in pregnancy. These can present in a variety of ways. They can cause mechanical obstruction leading to maternal and perinatal morbidity. Herein, we describe a patient with a vaginal leiomyoma misdiagnosed and operated as pelvic organ prolapse during the second trimester of pregnancy. She presented with a huge vaginal mass, foul-smelling vaginal discharge, difficulty in urination and defecation and septicemia. On examination, she had a large foul-smelling and necrotic mass protruding from the vagina with urethra lying outside the vagina, and sutures visible just above the mass on the anterior vaginal wall. She was admitted and a  lower segment caesarian section was done followed by transvaginal resection of the mass, and cystoscopy was done. Vaginal leiomyomas require surgical removal and it is usually curative and recommended as the initial treatment of choice, especially when the tumour is large enough to cause a potential obstacle to normal labour. Key Words: Vaginal leiomyoma, Pelvic organ prolapse, Pregnancy.

The practice of Burch Colposuspension versus Mid Urethral Slings for the treatment of Stress Urinary Incontinence in developing country.

OBJECTIVES: To compare the effectiveness and complications of Burch colposuspension and Mid Urethral Slings (MUS) for the treatment of Stress Urinary Incontinence (SUI). METHODS: We conducted a cross-sectional study of 162 patients who underwent surgery for SUI with Burch colposuspension (n=40), tension free vaginal tape (TVT) (n= 59) or transobturator tape (TOT) (n=63), from 2006 to 2014 at the Aga Khan University Hospital- Karachi. All three groups were assessed in terms of demographics, cure rates, intraoperative and postoperative complications at one and five years using incontinence impact questionnaire-short form-7 (IIQ-7) and urogenital distress inventory -short form-6 (UDI-6). RESULTS: Mean age of the participants in Burch, TVT and TOT group was 44.1 ± 7.4, 48.3 ± 8.9, 53.0 ± 9.4 respectively. Majority of patients in TVT group were premenopausal (59.3%) and postmenopausal in TOT group (53.9%). Most abdominal hysterectomies were done in Burch group (40) while vaginal hysterectomies and anterior and posterior colporrhaphy in TOT group (55). All the procedures had both subjective and objective cure rate of more than 82% at one year, with TVT having the highest success rate of 96.61%. The objective cure rate in Burch, TVT and TOT group at five years was 74.19%, 90.30% and 81.25% respectively. Intraoperative complications included hemorrhage in one patient during Burch procedure and bladder perforation in two cases of TVT, with no significant difference in short or long-term complications with either procedure. CONCLUSIONS: All the three procedures have equal efficacy and complication rates. Even though TVT is the new gold standard but in view of current debate regarding mesh related complications, there is a need to readdress Burch colposuspension for treatment of SUI.

Surgery for pelvic organ prolapse and stress urinary incontinence and female sexual functions: A quasi-experimental study.

OBJECTIVES: To assess the effect of pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI) on various domains of female sexual functions in patients before and after reconstructive surgery for these pelvic floor disorders. METHODS: We conducted a quasi-experimental study of 126 women aged 25-65 years, presenting with POP / SUI, from January 1st 2019 to December 31st 2019 at Aga Khan University Hospital. POP surgery was performed only in patients with symptomatic POP ≥ stage 2 according to POP-Q (quantification). Sexual functions were assessed using Female Sexual Function Index (FSFI) questionnaire, among sexually active women at baseline and 18 months after surgery. RESULTS: Mean age of the participants was 51.6, with a mean parity of four. Out of 126 patients, 31 patients underwent vaginal hysterectomy, pelvic floor repair and mid-urethral sling (MUS), 55 had vaginal hysterectomy with pelvic floor repair, 12 women had only pelvic floor repair and 10 patients had uterine suspension surgery for prolapse, while 18 patients underwent MUS operation alone for SUI. There was a statistically significant difference in female sexual functions after surgery for POP and/or SUI (p<0.01). This improvement was observed in both total and individual scores of each domain of FSFI with an overall improvement in sexual function from a mean of 18.5 pre-surgery to 20.8 post-surgery. CONCLUSIONS: This study reveals that women sexual functions are affected by POP and SUI and improve remarkably after reconstructive surgeries for these pelvic floor disorders.

Recurrent urinary tract infections in females.

Uncomplicated Urinary tract infections are common in adult women across the entire age spectrum, with mean annual incidence of 15% and 10% in those aged 15-39 and 40-79 years, respectively. Urinary tract infection (UTI), with its diverse clinical syndromes and affected host groups, remains one of the most common but widejly misunderstood and challenging infectious diseases encountered in clinical practice. Recurrent urinary tract infections (UTIs) present a significant problem for women and a challenge for the doctors who care for them. The diagnosis of uncomplicated UTI can be achieved best by a thorough assessment of patient symptoms with or without the addition of a urine dipstick test. Treatment should be based on the most recent guidelines, taking into account resistance patterns in the local community. The patient who suffers from recurrent UTIs can be treated safely and effectively with continuous antibiotic prophylaxis, post-coital therapy, or self-initiated treatment. This review article covers the latest trends in the management of recurrent UTI among women. Further research is needed regarding rapid diagnosis of UTI, accurate presumptive identification of patients with resistant pathogens, and development of new antimicrobials for drug-resistant UTI.