Pelvic floor muscle function in women presenting with pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: This observational study was undertaken to determine knowledge, prior instruction, frequency of performance, and ability to perform pelvic floor muscle exercises in a group of women presenting for evaluation of pelvic floor disorders. METHODS: Three hundred twenty-five women presenting for evaluation of pelvic floor disorders were questioned concerning knowledge and performance of pelvic floor muscle exercises (PMEs) and then examined to determine pelvic floor muscle contraction strength. RESULTS: The majority of women (73%) had heard of PMEs, but only 42% had been instructed to perform them and 62.5% stated they received verbal instruction only. Only 23.4% of patients could perform pelvic muscle contractions with Oxford Scale 3, 4, or 5 strengths. Increased age, parity, and stage of prolapse were associated with lower Oxford scores. CONCLUSIONS: Although most women with pelvic floor disorders are familiar with PMEs, less than one fourth could perform adequate contractions at the time of initial evaluation.

A randomized trial comparing methods of vaginal cuff closure at vaginal hysterectomy and the effect on vaginal length.

OBJECTIVE: The objective of the study was to compare the effect of horizontal versus vertical closure of the vaginal cuff during vaginal hysterectomy on vaginal length. STUDY DESIGN: Forty-three women were randomized to undergo horizontal (n = 23) or vertical (n = 20) vaginal cuff closure during vaginal hysterectomy at a community hospital. The primary outcome of vaginal length before and after surgery was compared by the Student t test and the paired t test. RESULTS: Preoperatively mean vaginal lengths in the horizontal and vertical groups were statistically similar (7.76 +/- 1.23 cm versus 8.28 +/- 1.39 cm, respectively; P = .21). Postoperatively the groups statistically differed (6.63 +/- 1.02 cm versus 7.93 +/- 1.18 cm, P < .001). The mean change in vaginal length was -1.13 +/- 1.15 cm and -0.35 +/- 0.91 cm, respectively (P = .01). Within-group comparisons revealed a statistical difference between pre- versus postmean vaginal length in the horizontal group (7.76 +/- 1.23 cm versus 6.63 +/- 1.02 cm; P < .001) and no difference within the vertical group (8.28 +/- 1.39 cm versus 7.93 +/- 1.18 cm; P = .11). CONCLUSION: Closing the vaginal cuff vertically is superior to horizontal closure for the purpose of preserving vaginal length.

The efficacy of the tension-free vaginal tape in the treatment of five subtypes of stress urinary incontinence.

PURPOSE: To determine the efficacy of tension-free vaginal tape (TVT) for the treatment of five sub-types of stress urinary incontinence (SUI). MATERIALS AND METHODS: A retrospective review was performed from November 1998 to November 2001 on all patients with SUI who underwent a TVT procedure either alone or with other reconstructive pelvic procedures. The patients were subdivided into five categories. Intrinsic sphincter deficiency (ISD) was defined by a maximum urethral closure pressure < 20 cm H2O or a mean Valsalva leak point pressure < 60 cm H2O above baseline. Urethral hypermobility (UH) was defined by a straining Q-tip angle greater than 30 degrees from the horizontal. Cure was defined as the subjective resolution of SUI without the development of voiding dysfunction or de novo urge incontinence. Improvement was defined as the subjective improvement of SUI without complete resolution or the subjective resolution of SUI occurring with the development of prolonged voiding dysfunction lasting greater than 6 weeks or de novo urge incontinence. Failure was defined as the subjective lack of improvement of SUI, the need for an additional procedure to correct SUI or the need for revision or takedown of the TVT for persistent voiding dysfunction or mesh erosion. RESULTS: The cure, improvement and failure rates for each of the following groups are respectively as follows: group 1 (+UH, -ISD) (n = 121): 101 (83.5%), 13 (10.7%), 7 (5.8%); group 2 (-UH, +ISD) (n = 22): 17 (77.3%), 3 (13.6%), 2 (9.1%); group 3 (+UH, +ISD) (n = 32): 26 (81.3%), 4 (12.5%), 2 (6.2%); group 4 (-UH, -ISD) (n = 25): 21 (84.0%), 3 (12.0%), 1 (4.0%); group 5 (occult SUI) (n = 67): 57 (85.1%), 10 (14.9%), 0 (0%). CONCLUSION: This study shows that the TVT is effective in treating all five sub-types of SUI.

Is previous cesarean section a risk for incidental cystotomy at the time of hysterectomy? A case-controlled study.

OBJECTIVE: The purpose of this study was to determine if previous cesarean section is an independent risk factor for incidental cystotomy at the time of hysterectomy. STUDY DESIGN: This is a case-controlled study that evaluated all cases of incidental cystotomy at the time of hysterectomy between January 1998 and December 2001. Five thousand and ninety-two hysterectomies were performed in the time period mentioned above, and 51 cases of incidental cystotomy were identified. Each case of incidental cystotomy was then matched to 3 controls with similar patient characteristics, medical histories, and surgical histories, as well as the absence of incidental cystotomy at the time of hysterectomy. RESULTS: Overall, 5092 hysterectomies were performed during the study period (total abdominal hysterectomy [TAH] 3140 [61.7%], total vaginal hysterectomy [TVH] 1519 [29.8%], laparoscopically-assisted vaginal hysterectomy [LAVH] 433 [8.5%]). Fifty-one cases of incidental cystotomy were identified (TAH: 24 [47.1%], TVH: 19 [37.3%], LAVH: 8 [15.7%]). The overall incidence of cystotomy was 1.0%. When considering TAH, there were 24/3141 (0.76%) cases of incidental cystotomy, with 8 (33%) of these patients with a history of previous cesarean section. During TVH, we encountered 19/1519 (1.3%) cases of incidental cystotomy, with 4 (21%) of these women having undergone a previous cesarean. Finally, during LAVH, there were 8/433 (1.8%) cases of incidental cystotomy. Five (62.5%) of these patients had a previous history of cesarean section. In comparison, 19/72 (26.4%) TAH controls had a previous history of cesarean. Four out of 57 (7.0%) TVH controls had a history of cesarean section. Finally, 2/24 (8.3%) LAVH controls had a history of previous cesarean. CONCLUSION: Previous cesarean section is indeed a significant risk factor for damage to the lower urinary tract at the time of hysterectomy (odds ratio [OR] 2.04; 95%CI 1.2-3.5). When analyzed separately, the OR of incidental cystotomy at the time of TAH, TVH, and LAVH in a woman with a history of previous cesarean was 1.26, 3.00, and 7.50, respectively. Only the value for LAVH was statistically significant (P = .005; 95%CI 1.8-31.4).

Paravaginal defects: prevalence and accuracy of preoperative detection.

The objective of this study was to determine the prevalence of paravaginal defects and to report the correlation between diagnosing a paravaginal defect preoperatively and observing the presence of one intraoperatively. This was a prospective study in which 77 patients with at least stage 2 prolapse of the anterior vaginal wall who desired surgical correction of their prolapse were assessed pre- and intraoperatively for the detection of a paravaginal defect. In order to differentiate a midline or central defect from a paravaginal defect, an index finger or ring forceps was placed vaginally toward each ischial spine separately. If the prolapse became reduced, the patient was clinically diagnosed with a paravaginal defect on that side. The intraoperative visualization or palpation of the pubocervical fascia detached from the arcus tendineus fasciae pelvis was used as the gold standard in diagnosing a paravaginal defect. The overall prevalence of a paravaginal defect in patients with at least stage 2 prolapse of the anterior vaginal wall was 37.7%. The sensitivities for detecting a left, right and bilateral paravaginal defect were 47.6, 40.0 and 23.5%, respectively, while the specificities for each side were 71.4, 67.3, and 80.0%, respectively. The overall prevalence of a paravaginal defect in patients with anterior vaginal wall prolapse is low. The standard clinical evaluation used to preoperatively detect a paravaginal defect in our hands is a poor predictor for the actual presence of a paravaginal defect.

Management of iatrogenic vaginal constriction.

OBJECTIVE: To prospectively assess the outcomes of four approaches to the surgical management of iatrogenic vaginal constriction. METHODS: A prospective study was initiated to evaluate all women who presented to our practice with the complaint of apareunia or dyspareunia secondary to postoperative vaginal constriction. All participants were initially offered and failed a trial of manual dilation. Between 1997 and 2002, 20 women underwent one of four surgical procedures: Z-plasty, vaginal incision of constriction ring, vaginal advancement, or placement of free skin graft. All 20 participants have been followed postoperatively, including assessment of dyspareunia and postoperative vaginal length and caliber. RESULTS: Three patients underwent Z-plasty, eight had incision of vaginal ring or ridge, eight had vaginal advancement, and one underwent placement of a free skin graft. Mean follow-up was 17 months (range, 3-32 months). Subjective cure was defined as resumption of pain-free vaginal intercourse. Objective cure was defined by findings on physical examination. The overall subjective and objective cure rates were 75% and 85%, respectively. CONCLUSION: The appropriate surgical procedure depends on the site and extent of the vaginal constriction, the state of the surrounding tissue, and the overall length and caliber of the vagina.

Complications and untoward effects of the tension-free vaginal tape procedure.

OBJECTIVE: To report our experience with our first 350 cases of tension-free vaginal tape (TVT), specifically assessing intraoperative complications, postoperative morbidity, and untoward effects of the procedure. METHODS: Although increased numbers of reports have documented the efficacy of the TVT procedure, there are minimal data about the incidence of complications and how they are managed. We performed a retrospective review of all patients undergoing the TVT procedure over a 4-year period to report intraoperative complications (bladder perforation and excessive bleeding), postoperative complications (de novo urge incontinence, voiding dysfunction, erosion, nerve injury, urinary retention, hematoma formation), and incidence of reoperation either for voiding dysfunction or for recurrent incontinence. RESULTS: A total of 350 patients were included in the study. Fifty-five percent (194) of women underwent the TVT procedure in conjunction with other vaginal surgery, and 45% (156) underwent the TVT alone. Seventy women (20%) had previous antiincontinence surgery. Intraoperative complications included 19 bladder perforations in 17 patients (4.9%) and three cases of significant bleeding (0.9%). Postoperatively, 17 women (4.9%) had voiding dysfunction and 42 (12%) required anticholinergic therapy beyond 6 weeks. Recurrent urinary tract infections developed in 38 (10.9%), erosion or poor healing in three (0.9%), hematoma in six (1.7%), and nerve injury in three (0.9%). Twenty-eight (8%) underwent urethral dilation in the postoperative period for varied amounts of voiding dysfunction. Of these, 82% were either improved or were cured. Six women (1.7%) underwent a takedown of the TVT procedure for continued voiding dysfunction, and two of these (33%) developed recurrent stress incontinence. To date, two patients (0.5%) have undergone another procedure for recurrent or persistent stress incontinence. CONCLUSION: The TVT procedure is efficacious for the correction of stress incontinence. Our data show that it is a safe procedure with an acceptable complication rate when performed by surgeons who have experience with retropubic and transvaginal antiincontinence procedures.

Urethral erosion of a tension-free vaginal tape.

BACKGROUND: Urethral dilation has been recommended to treat voiding dysfunction that may occur after placement of tension-free vaginal tape (TVT) for the treatment of stress urinary incontinence. We report on a case of urethral erosion by the tape secondary to repetitive urethral dilations after surgery. CASE: A urethral erosion by the tape was diagnosed by cystoscopy after three urethral dilations failed to resolve postoperative voiding dysfunction 8 weeks after the initial procedure. A partial tape revision with repair of the urethrotomy was performed, with resolution of the subject's voiding dysfunction. CONCLUSION: This report describes a potential complication of a recommended treatment for voiding dysfunction after placement of TVT.

Tension-free vaginal tape: a quality-of-life assessment.

OBJECTIVE: To assess whether tension-free vaginal tape (TVT) results in significant improvements in urinary incontinence and its effect on patients' quality of life (QOL) utilizing two validated questionnaires. METHODS: One hundred sixty-two tension-free vaginal tape procedures were performed at two sites between October 1998 and January 2001. All patients were requested to complete the Incontinence Impact Questionnaire (IIQ-7) and Urinary Distress Inventory (UDI-6) as part of their preoperative assessment. History, physical, and demographic data were also collected. All subjects underwent subtracted cystometry and urethral function tests prior to surgery. A combination of mail and phone follow-up was used to obtain postoperative IIQ-7 and UDI-6 scores in October 2001. Data were analyzed with the Wilcoxon matched-pairs signed-ranks test. RESULTS: One hundred fifty-one patients completed the pre- and postoperative quality-of-life forms and were included in the analysis. Mean follow-up was 22.1 months (range 6.1-49.8). There were significant improvements in postoperative scores for both the IIQ-7 and the UDI-6 (P <.001). Significant improvements were also seen in subscales measuring urge symptoms, stress incontinence symptoms, and symptoms of voiding dysfunction. These improvements were consistent, regardless of type or severity of stress incontinence. CONCLUSION: The IIQ-7 and UDI-6 are validated tools that can be used to provide some objective evidence for the impact of urinary incontinence on patients' lives. Utilizing these two validated quality-of-life tools we show that tension-free vaginal tape results in significant improvement in patient quality of life and symptoms of urgency, stress incontinence, and voiding dysfunction.