[French translation of "An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction" published in Int Urogynecol J 2010;21(1):5-26]. / Traduction française de la terminologie commune International Urogynecological Association (IUGA)/International Continence Society (ICS) sur les troubles de la statique pelvienne chez la femme initialement publiée dans Int Urogynecol J 2010;21(1):5-26.

INTRODUCTION AND HYPOTHESIS: Given its increasing complexity, the terminology for female pelvic floor disorders needs to be updated in addition to existing terminology of the lower urinary tract. To do this, it seems preferable to adopt a female-specific approach and build on a consensus based on clinical practice. METHODOLOGY: This paper summarizes the work of the standardization and terminology committees of two international scientific societies, namely the International Urogynecological Association (IUGA) and the International Continence Society (ICS). These committees were assisted by many external expert referees. A ranking into relevant major clinical categories and sub-categories was developed in order to allocate an alphanumeric code to each definition. An extensive process of 15 internal and external reviews was set up to study each definition in detail, with decisions taken collectively (consensus). RESULTS: Terminology was developed for female pelvic floor disorders, bringing together more than 250 definitions. It is clinically based and the six most common diagnoses are defined. The emphasis was placed on clarity and user-friendliness to make this terminology accessible to practitioners and trainees in all the specialties involved in female pelvic floor disorders. Imaging investigations (ultrasound, radiology, MRI) exclusively for women have been added to the text, relevant figures have also been included to complete the text and help clarify the meaning. Regular reviews are planned and are also required to keep the document up-to-date and as widely acceptable as possible. CONCLUSIONS: The work conducted led to the development of a consensual terminology of female pelvic floor disorders. This document has been designed to provide substantial assistance in clinical practice and research. LEVEL OF EVIDENCE: 4.

Symptoms of voiding dysfunction: what do they really mean?

Many women presenting with pelvic floor dysfunction will complain of voiding symptoms. This study examines the relationship between such symptoms and uroflowmetry parameters in 414 women with complaints of pelvic floor dysfunction who underwent free uroflowmetry with a weight transducer type flowmeter. Symptoms of voiding dysfunction were ascertained by interview, with symptoms rated positive if they occurred more than occasionally. Symptoms were correlated with maximum urine flow rate and maximum urine flow rate centiles: 356 women voided between 50 and 600 ml; these datasets were used for analysis. Average age was 57.4 years (range: 17-86). Symptoms of voiding dysfunction were common (62%): 26% of women described hesitancy, 28% a poor stream, 26% stop- start voiding, 15% straining to void, and 35% incomplete emptying/need to revoid. As a group, symptoms of voiding dysfunction were associated with reduced maximum urine flow rate centiles (28.1 vs 36.3, p= 0.011). The strength of the association varied markedly, with only hesitancy (p=0.002), poor stream (p<0.001), and stop-start voiding (p=0.014) reaching significance. Hesitancy, poor stream, and stop-start voiding were the only symptoms predictive of voiding impairment. Straining to void and the sensation of incomplete emptying or the need to revoid were not associated with a significant reduction in maximum flow rate centiles.

Female pelvic organ prolapse and voiding function.

It is accepted that pelvic organ prolapse impairs voiding, in particular as regards the anterior vaginal wall. The influence of central and posterior prolapse is more controversial. Mechanical effects, i.e. urethral distortion and compression, have been advanced as causative mechanisms. This study attempts to further elucidate the effect of prolapse on voiding. We investigated 228 patients with symptoms of lower urinary tract dysfunction and/or prolapse using independent flowmetry, clinical and ICS prolapse assessment and translabial ultrasound. As expected, age ( P<0.001), previous hysterectomy ( P = 0.002) and/or incontinence surgery ( P<0.001) negatively influenced flow. As regards prolapse, only enterocele had a consistently negative effect on flow ( P<0.001 for clinical staging, P = 0.002 for ICS assessment, P = 0.005 for ultrasound imaging). The relationship between anterior vaginal wall prolapse and voiding was complex: funneling and opening of the retrovesical angle on ultrasound was associated with improved voiding ( P<0.001), but a cystocele with intact retrovesical angle had the opposite effect ( P<0.001).

Irritative symptoms after colposuspension: are they due to distortion or overelevation of the anterior vaginal wall and trigone?

Symptoms of bladder irritability are common after incontinence surgery but their cause is unknown. This study tests the hypothesis that irritative symptoms after colposuspension are due to distortion of the trigone. As part of longitudinal follow-up studies, 175 women were examined 6 months to 12 years after either an open or a laparoscopic Burch colposuspension. The main outcome measures were symptoms of bladder irritability (frequency, nocturia and urge incontinence) and ultrasound findings (bladder neck position at rest and on Valsalva, the presence of a colposuspension ridge, ridge depth and ridge distance, and trigonal angle). Two positive associations between ultrasound parameters and symptoms of bladder irritability were observed: urge incontinence was more likely in the presence of bladder neck funneling, and women with nocturia had a higher trigonal angle. Increased distortion of the trigone was associated with a reduced incidence of urge incontinence in the subgroup of patients after laparoscopic colposuspension. The data presented in this study do not support the hypothesis that symptoms of bladder irritability are due to trigonal distortion or overelevation.

Ultrasound in the quantification of female pelvic organ prolapse.

OBJECTIVES: To evaluate the use of ultrasound in the quantification of prolapse and compare findings with clinical assessments obtained in a blind study. METHODS: In a prospective comparative clinical study, 145 patients referred for urogynecological assessment were examined clinically by one operator and by translabial ultrasound by another operator. RESULTS: Clinical staging and International Continence Society coordinates were obtained for all 145 patients, as were ultrasound coordinates for descent of the anterior and posterior vaginal walls. Eighteen percent of the uteri of those women who had not had a hysterectomy in the past could not be seen; none of these women suffered from uterine prolapse clinically. Correlation with the prolapse assessment system recently endorsed by the International Continence Society was good (r = 0.77 for uterine prolapse, r = 0.72 for anterior vaginal wall and r = 0.53 for posterior vaginal wall descent). CONCLUSIONS: This study demonstrates that translabial ultrasound can be used to quantify female pelvic organ prolapse. Correlation with the International Continence Society prolapse assessment system is good. The method may be particularly suitable for objective outcome assessment after surgical intervention.

Postpartum uterine retroversion causing bladder outflow obstruction: cure by laparoscopic ventrosuspension.

A case of chronic urinary retention due to bladder outflow obstruction presenting at 7 months postpartum, following a history of early puerperal voiding difficulties, is outlined. The cause was found to be a markedly retroverted uterus obstructing the urethra. Laparoscopic ventrosuspension was performed, converting preoperative urinary residuals of over 400 ml to zero postoperatively.

Urine flow rates and residual urine volumes in urogynecology patients.

Two hundred and fifty consecutive women referred because of symptoms of lower urinary tract dysfunction underwent a full clinical and urodynamic assessment. Their urine flow rates and residual urine volumes were analyzed. The urine flow rates of the urogynecology patients were found to be significantly less than those of an asymptomatic population. There were significant declines in urine flow rates in the presence of a previous hysterectomy and with increasing grades of prolapse, particularly uterine prolapse, cystocele and enterocele. Unlike the normal female population, there was also deterioration with increasing parity and age, the latter largely due to the increasing incidence of hysterectomy and prolapse with age. The 10th centile of the Liverpool Nomogram for the maximum urine flow rate was found to be the most useful discriminant for a final urodynamic diagnosis of voiding difficulties. Most urogynecology patients have no or small residual urine volumes, 74% <10 ml and 81% <30 ml (vs 95% <30 ml in asymptomatic women). In urogynecology patients residuals were larger where there had been a prior hysterectomy or with grade 2 or higher uterine prolapse, cystocele and enterocele. Mean residual was 14.8 ml (vs 4.8 ml in asymptomatic women). These data indicate a higher incidence of voiding difficulties (abnormally slow urine flow (under 10th centile) and/or abnormally high residual urine volume (over 30 ml) in urogynecology patients, particularly those with higher grades of prolapse and with prior hysterectomy.

Five-layer repair of rectovaginal fistula using a vaginal approach. A case report.

We present a case of a rectovaginal fistula which was revealed as an incidental finding at the time of posterior colporrhaphy. We describe a previously unreported 5-layer repair through a vaginal approach in preference to the more frequently reported approaches of endoanal flap or conversion to a fourth degree tear. The diagnosis and management of rectovaginal fistulas is discussed.

Do women with idiopathic sensory urgency have early interstitial cystitis?

Interstitial cystitis is rarely considered as a cause of urinary symptoms in referrals to gynaecology clinics. Recent concepts in the diagnosis of this condition mean that it is emerging as a much more common entity, with both early and late forms of the disease being described. Mast cell density in the detrusor muscle has been reported to be useful as a disease marker to substantiate the diagnosis of interstitial cystitis where no classical diagnostic features exist. We assessed mast cell counts in bladder biopsies from 27 women with idiopathic sensory urgency and 10 control patients about to undergo a colposuspension procedure for pure genuine stress incontinence; 30% of the study group had a clear increase in the detrusor muscle mast cell population (detrusor mastocytosis). No control patient showed such an increase. Early interstitial cystitis should be considered as a possible cause of lower urinary tract symptoms in patients with apparently idiopathic sensory urgency.

Urodynamic evaluation of lower urinary tract function in relation to total hysterectomy.

Although many women relate the onset of urinary symptoms to the operation of simple hysterectomy, many also have symptoms prior to surgery. Prospective study is therefore the most valid method of objective analysis of the effects of this operation upon micturition. To determine whether total hysterectomy is associated with increased postoperative vesicourethral abnormality, the incidences of urinary symptoms and urodynamic abnormality were assessed pre and postoperatively in 36 women undergoing hysterectomy. Preoperative symptoms were present in 58.3%, although urodynamically proven dysfunction was found in only 38.9%. After hysterectomy, 75% of women were symptomatic with a further 30.6% developing a urodynamic abnormality. The operation of total (simple) hysterectomy is associated with a significant increase in the subjective and objective incidence of vesicourethral dysfunction.

Urine flow rates in male and female urodynamic patients compared with the Liverpool nomograms.

The Liverpool male and female nomograms provide normal reference ranges for the maximum and average urine flow rates over a wide range of voided volumes. A known urine flow rate, in combination with the respective voided volume (and in men the age), can be converted into an equivalent centile ranking, using the equation for the relevant nomogram. Centile rankings allow the urine flow rates of specific male and female populations to be compared. The maximum and average urine flow rates of urodynamic patients (504 consecutive male and 168 consecutive female) were converted into centile rankings. These centile rankings were then compared with the respective urodynamic diagnoses. The median centile rankings for their maximum and average urine flow rates were 21 and 11 (male) respectively and 31 and 18 (female) (vs 50 for the normal populations). The low urine flow rates applied to all diagnostic groups, including those symptomatic men and women who were found to be urodynamically normal. Low urine flow rates may be one of a number of subtle manifestations of urological disease in these patients. Men with obstruction and women with voiding difficulties had the lowest urine flow rates. The 25th centile (men) and the 10th centile (women) appeared to be most appropriate lower limits of normality for both urine flow rates to identify those men more likely to be obstructed and those women at higher risk of voiding difficulties. Men and women with detrusor instability had the highest urine flow rates. Detrusor instability was present in 71% of men with centile rankings for the maximum urine flow rate over 50; 50% of women whose maximum urine flow rate centiles were over 90 had detrusor instability.

Transrectal ultrasound to measure bladder volumes in men.

Transrectal linear array ultrasound is described as a method in men to measure bladder volumes of 5 to 200 ml., overcoming the limitations of abdominal ultrasound at these smaller, although clinically important volumes. The mean error in a preliminary series with known volumes of 10 to 175 ml. was 18%. Statistical analysis of these data shows that an unknown bladder volume in milliliters can be calculated from the measurement of 2 sagittal bladder diameters, the height and depth, by the formula volume (ml.) = 5.3 X (height X depth) - 21. This equation when applied to measurements of a series of unknown bladder volumes had a mean error of 16%. Transrectal ultrasonic measurement of residual urine volumes (mostly those less than 175 ml.) provides a useful complement to visualization of the prostate by transrectal ultrasound.

Urodynamic evaluation prior to total hysterectomy: indications and incidence of abnormality.

Although it is recognized that total hysterectomy may be associated with subsequent urinary symptoms, many women are symptomatic prior to operation. However, only objective rather than subjective analysis can provide an accurate assessment of the preoperative state of the lower urinary tract. This study determined the incidence of preoperative, urodynamically-proven, vesicourethral dysfunction in women undergoing total hysterectomy. The incidence of urinary symptoms in 30 women awaiting hysterectomy was assessed and compared with the urodynamic findings. Sixteen (53%) of these patients had preoperative urinary symptoms, although bladder dysfunction was present in only 8 (27%). The presence of marked urinary symptoms in women awaiting hysterectomy warrants preoperative urodynamic investigation to identify any underlying bladder dysfunction.

The effects of simple hysterectomy on vesicourethral function.

Many women who present with symptoms of bladder dysfunction relate the onset to the operation of simple hysterectomy. A group of 42 women undergoing simple hysterectomy was studied prospectively. Urinary symptoms, urodynamic findings and sacral reflex latencies (SRLs) were assessed pre- and post-operatively. After hysterectomy the incidence of urinary symptoms increased from 58.3 to 75.0%. Vesicourethral dysfunction was altered in 30.6% of patients, 72.7% of whom had evidence of pelvic neuropathy as detected by SRLs. The results show that simple hysterectomy is associated with a significant incidence of post-operative vesicourethral dysfunction and that there is an identifiable neurological abnormality incurred at operation which is pertinent to the subsequent disordered voiding.