Posterior repair quantification (PR-Q) using key anatomical indicators (KAI): preliminary report.

INTRODUCTION AND HYPOTHESIS: Posterior vaginal compartment repairs (PR) have traditionally involved a subjective approach. We aim to quantify such repairs using key anatomical indicators (KAI). METHODS: At 50 consecutive PRs: perineal gap (PG); posterior vaginal vault descent (PVVD); mid-vaginal laxity (MVL-vault undisplaced/displaced); and recto-vaginal fascial laxity (RVFL) were measured. The total posterior vaginal length (TPVL) and from POP-Q, TVL, GH, Ap, Bp C, D were also measured. Surgical details deemed appropriate to each repair were recorded. RESULTS: A mean preoperative PG of 2.5 cm was reduced to 0.0 cm postoperatively by excision (100 % cases) with an average increase of 21.6 % in total vaginal length over that if the repair was commenced at the hymen. There was an average reduction of 25.0 % in the genital hiatus (GH). Mean PVVD was 5.3 cm overall; 6.4 cm for 31 out of 50 (62 %) undergoing sacrospinous colpopexy; 3.5 cm for 19 out of 50 (38 %) with no ligamentous vault fixation. An approximate "cut-off" for PVVD of 5 cm may assist with the differentiation of cases where vault fixation may be desirable. Up to 52 % (1.4/2.7 cm) of preoperative MVL displacement was due to vaginal vault descent. The MVL undisplaced (mean 1.3 cm) may better guide vaginal mucosal trimming. RVFL averaged just 0.8 cm with 22 out of 50 (44 %) RVFL being 0.5 cm or less, and not requiring any RVF plicatory sutures. CONCLUSIONS: It is possible to use KAI to assist the planning and execution of posterior vaginal compartment surgery. The PG, PVVD, MVL, and RVFL can indicate surgical measures in the perineum, vaginal vault, vaginal mucosa, and recto-vaginal space respectively.

Improving the clinical prediction of detrusor overactivity by utilizing additional symptoms and signs to overactive bladder symptoms alone.

INTRODUCTION AND HYPOTHESIS: We attempted to improve the accuracy of the clinical diagnosis of detrusor overactivity (DO) by using other significant clinical parameters in addition to overactive bladder (OAB) symptoms alone. METHODS: One thousand one hundred and forty women attending for their initial urogynecological assessment, including urodynamics, due to symptoms of pelvic floor dysfunction, underwent a comprehensive clinical and urodynamic assessment. Multivariate logistic regression analysis of a wide range of clinical parameters was used in order to determine a model of factors most accurately predicting the urodynamic diagnosis of DO. Data were separated according to women without DO; women with DO. The analysis involved the stepwise building of an optimal clinical model for predicting DO. RESULTS: In multivariate analysis, the OAB symptoms of urgency incontinence, urgency and nocturia (not frequency) were significantly associated with DO. Their prediction of DO was not particularly accurate (sensitivity 0.64; specificity 0.67). The addition of other significant clinical parameter, i.e. absent symptoms of stress incontinence; lower parity (0-1); no signs of prolapse, to the diagnostic model, resulted in marginally improved accuracy (area under the ROC curve increased from 0.70 to 0.74). CONCLUSIONS: Overactive bladder symptoms alone are not accurate in predicting DO. Adding other significant clinical parameters to the model resulted in a small statistical advantage, which is not clinically useful. An accurate clinical diagnosis of DO in women would appear to remain elusive.

Severe adolescent female stress urinary incontinence (SAFSUI): case report and literature review.

INTRODUCTION: Severe adolescent female stress urinary incontinence (SAFSUI) can be defined as female adolescents between the ages of 12 and 17 years complaining of involuntary loss of urine multiple times each day during normal activities or sneezing or coughing rather than during sporting activities. An updated review of its likely prevalence, etiology, and management is required. MATERIALS AND METHODS: The case of a 15-year-old female adolescent presenting with a 7-year history of SUI resistant to antimuscarinic medications and 18 months of intensive physiotherapy prompted this review. Issues of performing physical and urodynamic assessment at this young age were overcome in order to achieve the diagnosis of urodynamic stress incontinence (USI). Failed use of tampons was followed by the insertion of (retropubic) suburethral synthetic tape (SUST) under assisted local anesthetic into tissues deemed softer than the equivalent for an adult female. RESULTS: Whereas occasional urinary incontinence can occur in between 6 % and 45 % nulliparous adolescents, the prevalence of non-neurogenic SAFSUI is uncertain but more likely rare. Risk factors for the occurrence of more severe AFSUI include obesity, athletic activities or high-impact training, and lung diseases such as cystic fibrosis (CF). This first reported use of a SUST in a patient with SAFSUI proved safe and completely curative. Artificial urinary sphincters, periurethral injectables and pubovaginal slings have been tried previously in equivalent patients. CONCLUSIONS: SAFSUI is a relatively rare but physically and emotionally disabling presentation. Multiple conservative options may fail, necessitating surgical management; SUST can prove safe and effective.