Reconstructive surgery for women with female genital mutilation: A scoping review.

BACKGROUND: Female genital mutilation (FGM) is a global public health concern. However, reconstructive surgery remains unavailable in many countries. OBJECTIVES: This scoping review, guided by Joanna Briggs Institute (JBI) principles, explores indications, referral routes, eligibility, care pathways and clinical outcomes of reconstructive surgery for FGM. SEARCH STRATEGY: Medical Subject Headings (MeSH) terms and subject headings were searched in EMBASE, MEDLINE, SCOPUS, Web of Science and publicly available trial registers. SELECTION CRITERIA: Any primary experimental and quasi-experimental study addressing reconstructive surgery for FGM, and its impact on women, published before June 2023. DATA COLLECTION AND ANALYSIS: After removing duplicates from the search results, titles and abstracts were screened and data were extracted. Disagreements were resolved through panel discussion. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram depicts the search results and inclusion process. MAIN RESULTS: A total of 40 studies were included. Multidisciplinary teams were involved in 40% (16/40) of the studies, and psychosexual counselling was offered in 37.5% (15/40) of studies. Clitoral reconstruction using Foldes' technique was predominant (95%, 38/40). A total of 7274 women underwent some form of reconstruction. Post-surgery improvement was reported in 94% of the cases (6858/7274). The complication rate was 3% (207/7722 women with reconstruction). CONCLUSIONS: Further research and clinical trials are needed. Although the outcomes suggest improved sexual function and quality of life post-surgery, the evidence remains limited. Advocating surgical reconstruction for survivors of FGM is vital for addressing health disparities and potential cost-effectiveness.

Postoperative outcomes and urodynamic findings after continence mesh removal.

OBJECTIVE: To analyze urodynamics findings and patient-reported outcomes after removal of a mid-urethral mesh because data regarding outcomes following mesh removal vary in different studies, and mesh removal itself may have risks. METHODS: Women who were referred to the Female Pelvic Medicine and Reconstructive Surgery Department of University College London Hospital and underwent vaginal removal of a continence mesh between January 2014 and January 2020, were included. Patient clinical data and results of video-urodynamics investigations performed 4 months after mesh removal were collected and analyzed retrospectively. RESULTS: In all, 204 patients were included in the study. After mesh removal, 80.5% of patients reported recurrent stress urinary incontinence (SUI), 10.1% reported prolapse symptoms, 8% reported voiding dysfunction and 2.9% reported overactive bladder (OAB) symptoms. Video-urodynamics investigations confirmed the presence of SUI (67.6%), mixed urinary incontinence (14.3%), detrusor overactivity (DO) (6.8%) and voiding dysfunction in one patient. In two women a urethral stricture was described, and 10 women were deemed to have a significant cystocele. CONCLUSION: Recurrence of SUI was the most frequent finding after continence mesh removal, both symptomatically and objectively. Women seldom reported OAB symptoms, but urodynamics showed evidence of DO despite this. On the other hand, voiding dysfunction was often reported but less often proven on urodynamics.

Prevalence and severity of bowel disorders in the third trimester of pregnancy.

BACKGROUND: Bowel-related disorders are common conditions associated with pregnancy and are a cause of significant distress and healthcare burden. However, there is a lack of data in the literature about these disorders. OBJECTIVE: This study aimed to investigate bowel dysfunctions during the third trimester of pregnancy in a large cohort of women using the validated bowel domain of the Italian version of the Pelvic Floor Questionnaire for Pregnant and Postpartum Women. STUDY DESIGN: This was a secondary analysis of a multicenter cross-sectional study conducted in hospitals in Italy and Italian-speaking Switzerland. Women in the third trimester of pregnancy were asked to complete the Italian Pelvic Floor Questionnaire for Pregnant and Postpartum Women. RESULTS: During the study period, 927 pregnant women in the third trimester of pregnancy responded to the questionnaire and were included in the analysis. Overall bowel dysfunctions were reported by 29.6% of patients. Constipation was reported by 66.6% of pregnant women, whereas symptoms of obstructed defecation were reported by 49.9% of patients. In contrast, urgency was reported by 41.1% of patients. Incontinence to flatus and incontinence to stool were reported by 45.1% and 2.8% of patients, respectively. Moreover, age >35 years, familiarity with pelvic floor disorders, nicotine abuse, and pelvic floor contraction inability were identified as independent risk factors for at least 1 bowel symptom. CONCLUSION: Bowel symptoms are extremely common in the third trimester of pregnancy and can greatly affect a patient's quality of life; therefore, bowel symptoms deserve to be investigated and managed properly. The use of validated questionnaires represents a precious tool to investigate functional symptoms that could be very frequent and disabling in this particular period of life for women.

Prevalence and severity of sexual disorders in the third trimester of pregnancy.

BACKGROUND: Female sexual function in pregnancy is an under-investigated topic by care providers. This study aimed to investigate the sexual function and the impact of traditional risk factors for pelvic floor disorders (PFDs) during the third trimester of pregnancy. METHODS: This is a secondary analysis of a multicentre cross-sectional study conducted in eight hospitals in Italy and Italian-speaking Switzerland. Women at the third trimester of pregnancy aged 18 years and over completed the Italian-PFQPP questionnaire anonymously. RESULTS: 927 patients in the third trimester of pregnancy answered the questionnaire. 29.5% of women reported reduced or absent sexual activity. The less reported symptom was coital incontinence (1.3%), while painful intercourses was the most frequent one (50.3%). Nicotine abuse was associated with traumatic sexual intercourses, impaired vaginal sensibility, and negative impact on sexual life and well-being. Familiarity for pelvic floor disorder resulted as a risk factor for coital incontinence (OR=3.61). CONCLUSIONS: Sexual symptoms, with pain during intercourses being the most widely reported, are extremely common in the third trimester of pregnancy and can greatly affect quality of life. Familiarity for pelvic floor disorders and nicotine abuse resulted as significant risk factors for at least one sexual symptom.

Correlation between urinary symptoms and urodynamic findings: Is the bladder an unreliable witness?

OBJECTIVE: The role of urodynamics as the gold standard to investigate bladder function has recently been questioned. We aimed to evaluate the agreement of lower urinary tract symptoms and urodynamic diagnosis and to build predictive models. STUDY DESIGN: Patients who underwent urodynamics for pelvic floor disorders between 2008 and 2016 were retrospectively analyzed. Clinical evaluation investigated the presence of genital prolapse, stress urinary incontinence (SUI), overactive bladder (OAB), urge urinary incontinence (UUI), voiding symptoms (VS), and bulging symptoms. The degree of concordance/agreement between symptoms and corresponding urodynamic findings was measured. Multivariate models to predict specific urodynamic findings were built. RESULTS: 1972 women were analyzed. The best agreement was found for SUI and urodynamic SUI, with a proportion of agreement of 0.68 and a Cohen's Kappa of 0.37. Very poor agreement was found for OAB/UUI and detrusor overactivity, voiding dysfunction, and positive post-void residuals. Multivariate models resulted in poor accuracy for all urodynamic findings (AUC range 0.64-0.72). CONCLUSION: Lower urinary tract symptoms and gynecological examination are poor predictors of urodynamic findings. This confirms the role of urodynamic assessment in defining bladder function and providing precious information to counsel patients and establishing optimal clinical guidance.

Clinical and urodynamic predictors of Q-tip test urethral hypermobility.

BACKGROUND: Urodynamics and Q-tip test represent diagnostic tools for the assessment of stress urinary incontinence. The aim of the present study was to investigate the possibility to predict the Q-tip test urethral hypermobility on the basis of clinical and urodynamic parameters. METHODS: We analyzed all women performed urodynamics between 2008 and 2016 presenting urodynamic stress urinary incontinence. Symptoms were collected by the Incontinence Questionnaire-Short Form Questionnaire. RESULTS: A total of 501 women presented urodynamic stress incontinence, of which 270 had urethral hypermobility, according to the Q-tip test. Patients with urethral hypermobility were younger (P<0.0001) and presented a more advanced anterior compartment descensus according to the POP-Q system (Aa point P=0.0155; Ba point P=0.0374), a higher detrusor pressure at maximum flow (P=0.0075) and maximum flow rate compared to controls. CONCLUSIONS: Age, Aa POP-Q point and detrusor pressure at maximum flow were found to be independent predictors of Q-tip test urethral hypermobility. However, the final model cannot be used as an effective predictor of the Q-tip test result.

Detrusor underactivity prevalence and risk factors according to different definitions in women attending urogynecology clinic.

INTRODUCTION AND HYPOTHESIS: There is still no consensus on definitions of detrusor underactivity; therefore, it is difficult to estimate the prevalence. The primary objective of the study was to evaluate the prevalence of detrusor underactivity in a cohort of patients with pelvic floor disorders according to different proposed urodynamics definitions. The secondary objectives were to estimate the association between detrusor underactivity and symptoms, anatomy and urodynamic findings and to build predictive models. METHODS: Patients who performed urodynamic evaluation for pelvic floor disorders between 2008 and 2016 were retrospectively analyzed. Detrusor underactivity was evaluated according to Schafer's detrusor factor, Abrams' bladder contractility index and Jeong cut-offs. The degree of concordance between each method was measured with Cohen's kappa, and differences were tested using Student's t test, Wilcoxon test and Pearson's chi-squared test. RESULTS: The prevalence of detrusor underactivity among a cohort of 2092 women, concerning the three urodynamic definitions, was 33.7%, 37.0% and 4.1%, respectively. Age, menopausal status, voiding/bulging symptoms, anterior and central prolapse, first desire to void and positive postvoid residual were directly related to detrusor underactivity. Conversely, stress urinary incontinence, detrusor pressures during voiding and maximum flow were inversely associated. Final models for detrusor underactivity resulted in poor accuracy for all considered definitions. CONCLUSIONS: The prevalence of detrusor underactivity varies depending on the definition considered. Although several clinical variables resulted as independent predictors of detrusor underactivity, instrumental evaluation still plays a key role in the diagnosis.

Prevalence and severity of pelvic floor disorders in pregnant and postpartum women.

OBJECTIVE: This multicenter study aimed to evaluate risk factors, prevalence and severity of pelvic floor disorders (PFDs) as well as their consequences on women's emotional well-being, using a questionnaire validated specifically for pregnancy and postpartum. METHODS: Prospective study conducted in eight teaching hospitals in Italy and Italian-speaking Switzerland. Pregnant and postpartum women completed the Italian Pelvic Floor Questionnaire for Pregnancy and Postpartum anonymously. Prevalence of, severity of, and risk factors for PFDs were evaluated for all the four domains considered: bladder, bowel, prolapse, and sexual function. RESULTS: A total of 2007 women were included: 983 of the patients were bothered by at least one kind of PFD: bladder, bowel, and sexual dysfunction were more frequently reported. There were no significant differences in PFD prevalence between pregnancy and postpartum, except for bladder disorders, which were more prevalent in pregnancy. Familiarity for PFDs, pelvic floor contraction inability, cigarette smoking, body mass index more than 25 (calculated as weight in kilograms divided by the square of height in meters), and age more than 35 years were confirmed risk factors for the development of PFDs during pregnancy and postpartum. CONCLUSION: Almost half of the women included in the study suffered from PFD-related symptoms with important consequences on quality of life. Validated questionnaires are fundamental in early diagnosis and treatment of PFDs.

Inability to walk and persistent thigh pain after transobturator tape procedure for stress urinary incontinence: surgical management.

INTRODUCTION AND HYPOTHESIS: Groin pain after transobturator tape is often a self-limiting situation, but can occasionally persist and be associated with serious neurological sequelae. The video is aimed at presenting the surgical management of persistent groin pain and inability to walk after transobturator sling placement and subsequent partial removal. METHODS: The featured patient is a 31-year-old woman unable to walk after transobturator sling implantation 2 years before. She reported left thigh pain immediately after surgery that was not responsive to postoperative medication. Six months later, suburethral portion excision was performed but no pain relief was obtained. She was unable to walk, and needed a wheelchair. Electromyography showed axonal injury of the left obturator nerve. After providing proper informed consent, the patient was admitted for combined transvaginal and transcutaneous transobturator tape arm removal. RESULTS: The featured procedure was completed in 120 min and blood loss was <100 ml. No surgical complications were observed. The patient is currently doing left leg rehabilitation, has regained the ability to walk with the aid of a crutch, and the need for chronic pain control medication is greatly reduced. CONCLUSION: This represents a valid surgical approach for the late management of this mesh-related complication.

Urodynamic predictors of de novo overactive bladder after single-incision sling.

OBJECTIVE: To identify urodynamic predictors for de novo overactive bladder (OAB) after single-incision sling implantation. METHODS: This retrospective study analyzed women with pure, urodynamically proven stress urinary incontinence, without OAB, between 2008 and 2015, in a university hospital. De novo OAB was investigated during clinical interviews. RESULTS: A total of 192 patients were analyzed; 21 patients with de novo OAB were considered as group A while 171 control patients formed group B. Univariate analysis demonstrated that patients with de novo OAB have the first desire to void at a lower bladder volume (124 mL versus 160 mL, P = 0.0052), smaller maximum cystometric capacity (357 mL versus 406 mL, P = 0.0061), lower maximum flow (17 mL/s versus 23 mL/s, P = 0.0006), and higher bladder outlet obstruction index (BOOI; -11 versus -23, P = 0.0022) compared with controls. According to multivariate analysis, maximum cystometric capacity (parameter estimate [PE] =0.008, P = 0.04) and BOOI (PE = -0.029, P = 0.01) were independent urodynamic predictors of de novo OAB. The final model showed good predictive accuracy (area under the curve =0.81). CONCLUSION: The present study identified maximum cystometric capacity and BOOI as independent predictors of de novo overactive bladder after single-incision sling implantation. Therefore, preoperative urodynamics may be useful to improve preoperative counseling and to tailor surgical treatment.

Postpartum urinary retention: Absolute risk prediction model.

OBJECTIVES: To evaluate the incidence and assess clinical factors that can predict the occurrence of postpartum urinary retention (PPUR). PPUR is a puerperal condition defined as the inability to void over 6 hours after birth or after catheter removal in case of cesarean section, requiring catheterization. Lack of prompt diagnosis of this condition may lead to severe sequelae, including infection, chronic voiding difficulties, and renal failure. METHODS: This retrospective cohort study analyzed all deliveries from January 2011 to December 2017 in a single Italian university hospital. We used multivariate logistic regression to develop a predictive score for PPUR. RESULTS: By multivariate logistic regression, our analysis shows as minor (odds ratio [OR] < 2) risk factors for PPUR: non-Caucasian ethnicity (OR = 1.46, CI = 1.05-2.03), nulliparity (OR = 1.47, CI = 1.01-2.14), body mass index (BMI) at the end of the pregnancy <30 kg/m2 (OR = 1.54, CI = 1.10-2.17). On the other hand, epidural analgesia (OR = 3.93, CI = 2.96-5.22), meconium-stained amniotic fluid (OR = 2.07, CI = 1.54-2.77), nonoperative vaginal birth vs cesarean section (OR = 6.25, CI = 2.16-18.13), vacuum extraction vs cesarean section (OR = 8.80, CI = 2.86-27.01), pushing stage ≥60 minutes (OR = 3.00,CI = 2.26-3.97), and perineal tear (OR = 2.87, CI = 1.86-4.43) proved to be major (OR > 2) risk factors for PPUR. Using our final model (area under curve = 0.84), we created a nomogram for PPUR absolute risk calculation. Specifically, a 116-point cutoff might be used to identify high-risk patients who deserve more intensive micturition monitoring. CONCLUSIONS: Our study identified non-Caucasian ethnicity, nulliparity, and a BMI <30 kg/m2 at the end of the pregnancy as minor and epidural analgesia, meconium-stained amniotic fluid, vaginal nonoperative birth, vacuum extraction, pushing stage ≥60 minutes, and perineal tear as major independent risk factors for PPUR.

Italian validation of the German Pelvic Floor Questionnaire for pregnant and postpartum women.

OBJECTIVE: The only available validated questionnaire for pelvic floor disorders in pregnant and postpartum women is in German. The aim of this study was to translate and validate the German Pelvic Floor Questionnaire for pregnant and postpartum women into Italian. STUDY DESIGN: The questionnaire was translated into Italian by standardized procedural steps. The final version of the questionnaire was submitted to women in the third trimester of pregnancy or within 6 weeks post partum. Construct validity was tested using the Wilcoxon test, and internal consistency was tested using Cronbach's alpha. Test-retest reliability was measured with Cohen's kappa and intraclass correlation coefficient. RESULTS: Fifty women answered the questionnaire. Construct validity was demonstrated, as the questionnaire discriminated significantly between patients with and without symptoms for four domains of pelvic floor disorders. Internal consistency was satisfactory (0.62-0.93). Cohen's kappa values for test-retest reliability were between 0.46 (moderate agreement) and 1.00 (complete agreement). Intraclass correlation coefficients ranged between 0.93 and 0.96, indicating very satisfactory overall agreement for each functional domain. CONCLUSIONS: The Italian version of the German Pelvic Floor Questionnaire for pregnant and postpartum women is reliable, valid and consistent.

Transvaginal uterosacral ligament hysteropexy versus hysterectomy plus uterosacral ligament suspension: a matched cohort study.

INTRODUCTION AND HYPOTHESIS: Uterine-sparing procedures are associated with shorter operative time, less blood loss and faster return to activities. Moreover, they are attractive for patients seeking to preserve fertility or concerned about the change of their corporeal image and sexuality after hysterectomy. This study aimed to compare outcomes of transvaginal uterosacral hysteropexy with transvaginal hysterectomy plus uterosacral suspension. METHODS: This retrospective study compared all patients who underwent uterosacral hysteropexy for symptomatic prolapse at our institute to matched control patients who underwent hysterectomy plus uterosacral ligament suspension. Anatomic recurrence was defined as postoperative prolapse stage ≥ II or reoperation for prolapse. Subjective recurrence was defined as the presence of bulging symptoms. PGI-I score was used to evaluate the patients' satisfaction. RESULTS: One hundred four patients (52 for each group) were analyzed. Mean follow-up was 35 months. Hysteropexy was associated with shorter operative time and less bleeding compared with hysterectomy (p < 0.0001), without differences in complication rates. Moreover, overall anatomic and subjective cure rate and patient satisfaction were similar between groups. However, hysteropexy was found to be associated with a significantly higher central recurrence rate (21.2% versus 1.9%, p = 0.002), mostly related to cervical elongation, and subsequently a higher reoperation rate (13.5% versus 1.9%, p = 0.04). A 42.9% pregnancy rate in patients still desiring childbirth was found. CONCLUSIONS: Transvaginal uterosacral hysteropexy resulted in similar objective and subjective cure rates, and patient satisfaction, without differences in complication rates, compared with vaginal hysterectomy. However, postoperative cervical elongation may lead to higher central recurrence rates and need for reoperation.

Long-term outcomes and five-year recurrence-free survival curves after native-tissue prolapse repair.

OBJECTIVE: To evaluate the long-term objective and subjective outcomes to build recurrence-free survival curves after mesh-free uterosacral ligament suspension and to evaluate the long-term impact of prognostic factors on outcome measures. METHODS: A retrospective study analyzed 5-year follow-up after repair of primary prolapse through high uterosacral ligament suspension. Bulging symptoms and post-operative prolapse stage II or above were considered subjective and objective recurrences, respectively. The cumulative proportion of relapse-free patients in time was analyzed by Kaplan-Meier curves. RESULTS: A total of 353 women were analyzed. Five-year recurrence rates were 15.0% for objective recurrence, 13.0% for subjective recurrence, and 4.0% for the combined objective and subjective recurrences. Premenopausal status was shown to be a risk factor for anatomic (P=0.022), symptomatic (P=0.001), and combined (P=0.047) recurrence. Conversely, anterior repair was shown to be a protective factor for symptomatic (P=0.012) and combined (P=0.002) recurrence. Most of the recurrences occurred within 2 years after surgery. CONCLUSION: Long-term outcomes after high uterosacral ligament suspension were satisfactory. Premenopausal status and lack of anterior repair represented risk factors for recurrence in the long term.