Does preoperative locally applied estrogen treatment facilitate prolapse-associated symptoms in postmenopausal women with symptomatic pelvic organ prolapse? A randomised controlled double-masked, placebo-controlled, multicentre study.

OBJECTIVE: To evaluate whether locally applied vaginal estrogen affects prolapse-associated complaints compared with placebo treatment in postmenopausal women prior to surgical prolapse repair. DESIGN: Randomised, double-masked, placebo-controlled, multicentre study. SETTING: Urogynaecology unit at the Medical University of Vienna and University Hospital of Tulln. POPULATION: Postmenopausal women with symptomatic pelvic organ prolapse and planned surgical prolapse repair. METHODS: Women were randomly assigned local estrogen cream or placebo cream 6 weeks preoperatively. MAIN OUTCOME MEASURES: The primary outcome was differences in subjective prolapse-associated complaints after 6 weeks of treatment prior to surgery, assessed with the comprehensive German pelvic floor questionnaire. Secondary outcomes included differences in other pelvic floor-associated complaints (bladder, bowel or sexual function). RESULTS: Out of 120 women randomised, 103 (86%) remained for the final analysis. After 6 weeks of treatment the prolapse domain score did not differ between the estrogen and the placebo groups (4.4 ± 0.19 versus 4.6 ± 0.19; mean difference, -0.21; 95% CI -0.74 to 0.33; P = 0.445). Multivariate analysis, including only women receiving the intervention, showed that none of the confounding factors modified the response to estradiol. CONCLUSIONS: These results demonstrate that preoperative locally applied estrogen does not ameliorate prolapse-associated symptoms in postmenopausal women with symptomatic pelvic organ prolapse. TWEETABLE ABSTRACT: Preoperative local estrogen does not ameliorate prolapse-associated symptoms in postmenopausal women with pelvic organ prolapse.

Knowledge of pelvic organ prolapse in patients and their information-seeking preferences: comparing Vienna and Moscow.

INTRODUCTION AND HYPOTHESIS: We hypothesized that knowledge of pelvic organ prolapse (POP) and patient information-seeking preferences are the same in the two capital cities. METHODS: First-visit patients were recruited at tertiary referral urogynaecological units in Vienna (137) and in Moscow (112). A 16-item scale was used to assess the patient knowledge of POP. The 16 items comprised 12 specific items taken from the Prolapse and Incontinence Knowledge Questionnaire (PIKQ) and four added items. The preliminary psychometric assessment of the knowledge scales in German and Russian was performed in the Vienna and in Moscow centres. RESULTS: The mean total knowledge scores in patients in Vienna and in Moscow were not significantly different: 9.7 ± 3.5 vs. 9.8 ± 2.9 (p = 0.92). Patients in Vienna were more likely to answer questions about the pathogenesis of POP correctly. Patients in Moscow achieved higher scores for items assessing knowledge about the diagnosis of POP. Women in the two study groups equally preferred to obtain information about POP from medical specialists (72 % and 82 %; p = 0.61), followed by friends and family for patients in Vienna (25 %), and the internet for patients in Moscow (23 %). Patients in Vienna were more likely to use printed sources (18 % and 7 %; p = 0.001) than patients in Moscow. CONCLUSIONS: The mean level of knowledge of POP did not differ between patients in Vienna and patients in Moscow. The differences between the specific knowledge domains might be explained by different cultural preferences for seeking health information and by the range of the information sources available.

The Problem of Polypharmacy in Female Patients with Overactive Bladders - Cross-Sectional Study in a Specialist Outpatient Department.

Background: The consumption of certain drugs can cause urinary incontinence. The aim of this study is to determine the frequency of consumption of drugs that can favour incontinence, the incidence of polypharmacy and the incidence of potentially dangerous drug-drug interactions in female patients suffering from overactive bladder (OAB) who presented to a urogynaecological outpatient department. Methods: We undertook a retrospective case series study. The data from 100 female patients who attended the urogynaecological outpatient department of the Vienna General Hospital [VGH; Allgemeinen Krankenhauses Wien (AKH)] in the period from 20. 07. 2010 to 30. 08. 2011 were evaluated. The patients suffered either from an OAB or mixed incontinence with predominantly urge components. Among other factors, we were interested in the drugs taken for longer periods of time as well as the general and the urogynaecological case histories. 15 parameters were recorded: age, BMI, menopausal status, parity, pelvic organ prolapse, DIAPPERS criteria (delirium, infection (urinary), atrophic urethritis and vaginitis, pharmaceuticals, psychological disorders (especially depression), excessive urine output, restricted mobility, stool impaction), drug side effects and drug-drug interactions. A descriptive statistical analysis was performed. The drugs were checked with the help of a drug information system (Intranet-KH [V 6.0]). Of particular interest was the consumption of drugs that could favour urinary incontinence as an adverse side effect. In addition the frequency of polypharmacy and the frequency of potentially health-threatening drug combinations were registered. Results: 57 % of the patients consumed at least one drug that could reinforce urinary incontinence. The frequency of polypharmacy was 38 %. In 45 % of the patients the possibility for health-damaging interactions existed as a result of the consumed drugs. Conclusion: The frequencies of consumption of drugs that can favour urinary incontinence and of polypharmacy are high among the patients who attend a specialist outpatient department for urinary incontinence. This emphasises the importance of a complete drug history in the diagnostic work-up for urinary incontinence.

Vaginal prolapse surgery with transvaginal mesh: results of the Austrian registry.

INTRODUCTION AND HYPOTHESIS: Several mesh repair systems for pelvic organ prolapse (POP) were introduced into clinical practice with limited data on safety, complications or success rates, and impact on sexual function. The Austrian Urogynecology Working Group initiated a registry to assess the use of transvaginal mesh devices for POP repair. We looked at perioperative data, as well as outcomes at 3 and 12 months. METHODS: Between 2006 and 2010 a total of 20 gynecology departments in Austria participated in the Transvaginal Mesh Registry. Case report forms were completed to gather data on operations, the postoperative course, and results at 3 and 12 months. RESULTS: A total of 726 transvaginal procedures with 10 different transvaginal kits were registered. Intra- and perioperative complications were reported in 6.8%. The most common complication was increased intraoperative bleeding (2.2%). Bladder and bowel perforation occurred in 6 (0.8%) and 2 (0.3%) cases. Mesh exposure was seen in 11% at 3 and in 12% at 12 months. 24 (10%) previously asymptomatic patients developed bowel symptoms by 1 year. De novo bladder symptoms were reported in 39 (10%) at 3 and in 26 (11%) at 12 months. Dyspareunia was reported by 7% and 10% of 265 and 181 sexually active patients at 3 and 12 months postoperatively respectively. CONCLUSIONS: The 6.8% rate of intra- and perioperative complications is in line with previous reports. Visceral injury was rare. The 12% rate of mesh exposure is consistent with previous series.

Guidelines for the management of third and fourth degree perineal tears after vaginal birth from the Austrian Urogynecology Working Group.

The purpose of this guideline is to provide a decision aid for diagnosis, treatment, and follow-up of patients with major perineal tears and thus minimize the risk of persistent symptoms. In 2007, the "Guideline for the management of third and fourth degree perineal tears after vaginal birth" was established by members of the Austrian Urogynecologic Working Group (AUB). The guideline was updated in 2011, including literature published up to 30 November 2011. The DELPHI method was used to reach consensus. Evidence-based and consensus-based statements were defined for epidemiology, risk factors, classification, diagnosis, surgery, and follow-up of major perineal lacerations at vaginal birth.

Interobserver repeatability of three- and four-dimensional transperineal ultrasound assessment of pelvic floor muscle anatomy and function.

OBJECTIVE: To evaluate the interobserver repeatability of measurement of the pubovisceral muscle and levator hiatus, and the position of related organs, during rest, muscle contraction and Valsalva maneuver using three- and four-dimensional (3D and 4D) transperineal ultrasound. METHODS: Seventeen women were included in the study. The position and dimensions of the pubovisceral muscle and levator hiatus in patients at rest and during contraction and Valsalva were determined from stored 3D and 4D ultrasound volumes. Analyses were conducted offline by two observers blinded to the clinical data and to each others' measurements. RESULTS: Measurements of levator hiatal dimensions at rest demonstrated intraclass correlation coefficient (ICC) values of 0.92 to 0.96. The ICC values for pubovisceral muscle thickness at rest varied between good and very good (ICC, 0.61-0.93), regardless of plane. During contraction, the ICC values for all measured parameters were very good, varying between 0.61 and 0.92. Measurement of the transverse diameter of the levator hiatus during the Valsalva maneuver showed good reliability (ICC, 0.86), but assessment of the anterior and posterior borders of the levator hiatus was only possible in 29% of cases. CONCLUSIONS: 3D and 4D transperineal ultrasound measurement of the pubovisceral muscle and levator hiatus is reliable in women with no or minor symptoms of prolapse at rest and during contraction. The technique for recording during the Valsalva maneuver requires improvement if it is to be useful in the diagnosis of pelvic organ prolapse.

Prevalence of female sexual dysfunction in gynecologic and urogynecologic patients according to the international consensus classification.

OBJECTIVES: To evaluate the prevalence of female sexual dysfunction (FSD) in an outpatient gynecologic and urogynecologic clinic using the current International Consensus Classification. METHODS: One hundred fifty-nine patients were asked to answer an anonymous survey about FSD. Patients in the gynecologic (group 1) and urogynecologic (group 2) clinics were compared. RESULTS: The mean age in group 1 was 37.8 years (range 20 to 76) and in group 2 was 55.7 years (range 18 to 82). The prevalence of FSD was 50% in group 1 and 48% in group 2; 86% of group 1 and 66% of group 2 patients had been sexually active within the past 2 years. The differences found in FSD according to the consensus panel classification achieved no significance. Of the 159 patients, 96% were not embarrassed by filling out this questionnaire about their sexual function. CONCLUSIONS: No statistically significant difference in FSD was found between the younger and older patients seeking help in a gynecologic or urogynecologic outpatient clinic. Because of the high incidence of FSD, we recommend integrating the inquiry about female sexual health concerns into routine gynecologic care. The simple survey based on the International Consensus Conference Classification of FSD gives reliable results, and this systematic framework facilitates methodologic examination.

Genetic disorders in premature ovarian failure.

This review presents the genetic disorders associated with premature ovarian failure (POF), obtained by Medline, the Cochrane Library and hand searches of pertinent references of English literature on POF and genetic determinants cited between the year 1966 and February 2002. X monosomy or X deletions and translocations are known to be responsible for POF. Turner's syndrome, as a phenotype associated with complete or partial monosomy X, is linked to ovarian failure. Among heterozygous carriers of the fragile X mutation, POF was noted as an unexpected phenotype in the early 1990s. Autosomal disorders such as mutations of the phosphomannomutase 2 (PMM2) gene, the galactose-1-phosphate uridyltransferase (GALT) gene, the FSH receptor (FSHR) gene, chromosome 3q containing the Blepharophimosis gene and the autoimmune regulator (AIRE) gene, responsible for polyendocrinopathy-candidiasis-ectodermal dystrophy, have been identified in patients with POF. In conclusion, the relationship between genetic disorders and POF is clearly demonstrated in this review. Therefore, in the case of families affected by POF a thorough screening, including cytogenetic analysis, should be performed.

Leiomyoma in the space of Retzius: a report of 2 cases.

Leiomyomas most frequently occur in the genitourinary and gastrointestinal system. This report discusses clinical and pathologic findings of 2 leiomyomas in the pubovesical space, a location that has not been described before. Different operative approaches were used for excision. Immunohistochemical examination for the presence of estrogen and progesterone receptors was performed.

Three-dimensional ultrasound of the female urethra: comparing transvaginal and transrectal scanning.

OBJECTIVES: To compare transvaginal and transrectal three-dimensional ultrasound in determining the morphology and measurements of the female urethra. DESIGN: Sixty-five women who had not had surgery for incontinence or pelvic floor descent had transvaginal and transrectal sonography using a 7.5-MHz mechanical sector endoprobe with three-dimensional facilities. The multiplanar display of the scanned volumes allowed detailed morphologic assessment of the urethra and the measurement of distances and volumes. Statistical endpoints were: sagittal urethral diameter, maximum rhabdosphincter length and thickness, maximum thickness of the smooth muscle complex, and the volumes of the rhabdosphincter and the smooth muscle complex. Values were compared between the two approaches using Student's t-test and Bland-Altman analysis. RESULTS: Both vaginal and rectal scans were feasible. However, significant differences between the two approaches were found for the sagittal diameter of the urethra (8.4 +/- 1.9 mm on vaginal vs. 11.5 +/- 2.2 mm on rectal scans, P < 0.01) and the transverse diameter of the urethra's smooth muscle complex (11.2 +/- 0.3 mm on vaginal vs. 8.6 +/- 0.2 mm on rectal scans, P < 0.001). No other variables showed significant differences. Compression of the urethra and displacement under the symphysis pubis were observed when the ultrasound probe was applied vaginally. Bland-Altman analysis showed acceptable variability for differences of distances but considerable variability for the differences of volumes. CONCLUSION: The female urethra can be examined both vaginally and rectally by three-dimensional ultrasound. A transvaginally applied probe seems to have a compression effect on the urethra.

[Diagnostic imaging in gynecological emergencies]. / Der gynäkologische Notfall aus radiologischer Sicht.

A wide spectrum of differential diagnosis exists in case of gynaecological emergencies which also includes gastrointestinal and urologic diseases. Radiologic imaging primarily bases on sonography, computed tomography and magnetic resonance imaging are used for subsequent evaluation. The detailed algorithm is oriented on clinical symptoms and signs. The most important signs are left and right lower quadrant abdominal pain, vaginal bleeding, and sudden onset of pain in the breast.

Are commonly used self-report inventories suitable for screening postpartum depression and anxiety disorders?

OBJECTIVE: The utility of several self-report symptom inventories were examined for detecting postpartum depression (MDD) and anxiety disorders (AD). METHOD: Fifty women (3 or 6 months postpartum), at heightened risk for MDD, completed several depression and anxiety symptom checklists. Psychiatric diagnoses were obtained via SCID interview. RESULTS: Rates of MDD (n=9) and AD (n=9) were equivalent in this sample, with minimal diagnostic overlap. While all the self-report depression inventories screened accurately for MDD, none discriminated AD sensitively and reliably. CONCLUSION: The frequent occurrence of AD emphasizes the need to identify appropriate screening instruments for postpartum anxiety disorders.

Spontaneous pneumomediastinum.

In this paper two cases of spontaneous pneumomediastinum, occurring in a patient with diabetic ketoacidosis and in a patient with bronchial asthma, are presented. We describe the radiological findings, the differential diagnosis and the important radiographic considerations in establishing the diagnosis. In addition, we discuss the anatomical pathways and review the pathophysiological mechanisms responsible for the development of respiratory spontaneous pneumomediastinum.

Imaging of the brain using the fast-spin-echo and gradient-spin-echo techniques.

The aim of our study was to compare gradient-spin-echo (GRASE) to fast-spin-echo (FSE) sequences for fast T2-weighted MR imaging of the brain. Thirty-one patients with high-signal-intensity lesions on T2-weighted images were examined on a 1.5-T MR system. The FSE and GRASE sequences with identical sequence parameters were obtained and compared side by side. Image assessment criteria included lesion conspicuity, contrast between different types of normal tissue, and image artifacts. In addition, signal-to-noise, contrast-to-noise, and contrast ratios and were determined. The FSE technique demonstrated more lesions than GRASE and with generally better conspicuity. Smaller lesions in particular were better demonstrated on FSE because of lower image noise and slightly weaker image artifacts. Gray-white differentiation was better on FSE. Ferritin and hemosiderin depositions appeared darker on GRASE, which resulted in better contrast. Fatty tissue was less bright on GRASE. With current standard hardware equipment, the FSE technique seems preferable to GRASE for fast T2-weighted routine MR imaging of the brain. For the assessment of hemosiderin or ferritin depositions, GRASE might be considered.

Fast flair imaging of the brain using the fast spin-echo and gradient spin-echo technique.

The purpose of this study was to compare the gradient spin-echo (GRASE) to the fast spin-echo (FSE) implementation of fast fluid-attenuated inversion recovery (FLAIR) sequences for brain imaging. Thirty patients with high signal intensity lesions on T2-weighted images were examined on a 1.5 T MR system. Scan time-minimized thin-section FLAIR-FSE and FLAIR-GRASE sequences were obtained and compared side by side. Image assessment criteria were lesion conspicuity, contrast between different types of normal tissue, image quality, and artifacts. In addition, contrast ratios and contrast-to-noise ratios were determined. Compared to FSF, the GRASE technique allowed a 17% reduction in scan time but conspicuity of small lesions in particular was significantly lower on FLAIR-GRASE images because of higher image noise and increased artifacts. Gray-white differentiation was slightly worse on FLAIR-GRASE. Physiological ferritin deposition appeared slightly darker on FLAIR-GRASE images and susceptibility artifacts were stronger. Fatty tissue was less bright with FLAIR-GRASE. With current standard hardware equipment, the GRASE technique is not an adequate alternative to FSE for the implementation of fast FLAIR sequences in routine clinical MR brain imaging.