Where to for pelvic organ prolapse treatment after the FDA pronouncements? A systematic review of the recent literature.

INTRODUCTION: With the publication of the updated US Food and Drug Administration (FDA) communication in 2011 on the use of transvaginal placement of mesh for pelvic organ prolapse (POP) it is appropriate to now review recent studies of good quality on POP to assess the safety and effectiveness of treatment options and determine their place in management. METHODS: A systematic search for studies on the conservative and surgical management of POP published in the English literature between January 2002 and October 2012 was performed. Studies included were review articles, randomized controlled trials, prospective and relevant retrospective studies as well as conference abstracts. Selected articles were appraised by the authors regarding clinical relevance. RESULTS: Prospective comparative studies show that vaginal pessaries constitute an effective and safe treatment for POP and should be offered as first treatment of choice in women with symptomatic POP. However, a pessary will have to be used for the patient's lifetime. Abdominal sacral colpopexy is effective in treating apical prolapse with an acceptable benefit-risk ratio. This procedure should be balanced against the low but non-negligible risk of serious complications. The results of native tissue vaginal POP repair are better than previously thought with high patient satisfaction and acceptable reoperation rates. The insertion of mesh at the time of anterior vaginal wall repair reduces the awareness of prolapse as well as the risk of recurrent anterior prolapse. There is no difference in anatomic and subjective outcome when native tissue vaginal repairs are compared with multicompartment vaginal mesh. Mesh exposure is still a significant problem requiring surgical excision in approximately ≥ 10 % of cases. The ideal mesh has not yet been found necessitating more basic research into mesh properties and host response. Several studies indicate that greater surgical experience is correlated with fewer mesh complications. In women with uterovaginal prolapse uterine preservation is a feasible option which women should be offered. Randomized studies with long-term follow-up are advisable to establish the place of uterine preservation in POP surgery. CONCLUSION: Over the last decade treatment of POP has been dominated by the use of mesh. Conservative treatment is the first option in women with POP. Surgical repair with or without mesh generally results in good short-term objective and functional outcomes. However, basic research into mesh properties with host response and comparative studies with long-term follow-up are urgently needed.

Urogenital symptoms and resulting discomfort in non-institutionalized Dutch women aged 50-75 years.

The aim of this study was to determine the prevalence of urogenital symptoms in non-institutionalized Dutch women aged 50-75 years, and the degree of discomfort suffered as a result. A questionnaire was sent to 2157 women, a sample representative of the female population aged 50-75 years with respect to age, marital status, level of education and menopausal age. The usable response was 81.6% (n = 1761). The overall prevalence of vaginal dryness, soreness and dyspareunia was 27%. The prevalence of micturition symptoms, urinary incontinence and recurrent urinary tract infection was 36%. The prevalence estimates for vaginal dryness and urinary incontinence showed a linear decrease with increasing age. Almost half of the symptomatic women reported moderate to severe discomfort. One-third of those affected received medical care. Previous hysterectomy had no effect on the reported prevalence estimates. Hysterectomized women reported moderate to severe complaints more often than non-hysterectomized ones. There were no significant differences in prevalence estimates between former and current smokers and non-smokers.

A study of European womens' experience of the problems of urogenital ageing and its management.

OBJECTIVES: A six country Pan-European study of aspects of urogenital ageing (UGA). METHODS: The study was carried out using a stratified random sample of 3000 women between the ages of 55 and 75 years. RESULTS: A total of 30% suffered from UGA symptoms, of whom 60% made efforts to alleviate their UGA problems, most commonly using HRT. There were some international differences regarding womens' perceptions of HRT, sexual relationships, prevalence and treatment of UGA problems and their attitudes to them across the six European States. CONCLUSIONS: Despite some international differences there was a generally similar experience of UGA problems across the six European populations studied, with a minority of women suffering significantly, however the distress of that subgroup highlighted the need for health professionals to appreciate the impact of UGA on those affected and to understand that many of these older women may be reticent in seeking help.

[Urogenital symptoms and their resulting discomfort in non-institutionalized 50-to-75-year-old Dutch women]. / Urogenitale verschijnselen en hinder daarvan bij thuiswonende Nederlandse vrouwen van 50 tot 75 jaar.

OBJECTIVE: To determine the prevalence of urogenital symptoms in non-institutionalized Dutch women, aged 50 to 75 years, and the degree of discomfort. DESIGN: Cross-sectional study. SETTING: Nationwide investigation. METHOD: A questionnaire was sent to 2157 non-institutionalized Dutch women aged 50 to 75 years. The survey sample was representative of the female population aged 50 to 75 years with respect to age, marital status, level of education and menopausal age. RESULTS: The usable response was 81.6% (n = 1761). The overall prevalence of vaginal dryness, soreness and dyspareunia was 27%. The prevalence of micturition symptoms, urinary incontinence and recurrent urinary tract infections was 36%. The prevalence estimates for vaginal dryness and urinary incontinence showed a linear decrease with increasing age. Almost half of the symptomatic women reported moderate to severe discomfort. One-third of those affected received medical care. Previous hysterectomy had no effect on the reported prevalence estimates. Hysterectomized women reported moderate to severe complaints more often than non-hysterectomized ones. CONCLUSION: The prevalence of urogenital symptoms in non-institutionalized Dutch women aged 50 to 75 years, was high: 47%. Of these women, 40% to 60% experienced discomfort, but only one-third had sought medical advice. These urogenital problems will probably increase in the coming decades.

The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension.

The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension for correction of stress urinary incontinence were assessed in a prospective study. Ninety women undergoing surgery for the first time because of genuine stress incontinence were studied. A full clinical examination including simultaneous urethrocystometry according to a standardized methodology with the patients in the supine, sitting, and standing positions was performed preoperatively, 3 months postoperatively, and again 1 to 2 years later. Clinical follow-up continued for 5 to 7 years. Neither surgical anterior vaginal repair nor Burch colposuspension affected the resting variables of the urethral sphincter mechanism. After Burch colposuspension the transmitted intraabdominal pressure to the urethra significantly increased in all recording positions in all women who were successfully treated. After successful anterior colporrhaphy, the increase in pressure transmission from the abdomen to the urethra was less prominent and was only present in the sitting and standing positions. The postural changes in the urethral pressure profile characteristic of stress urinary incontinence were still present even after successful restoration of continence. The impact of successful surgery for stress incontinence is the enhancement of transmission of the intraabdominal pressure rise to the proximal urethra. This is achieved primarily by anatomic alterations rather than by altering urethral sphincter function. Burch colposuspension was more effective for the correction of genuine stress incontinence than was anterior vaginal repair.

Female urethral pressure profile; reproducibility, axial variation and effects of low dose oral contraceptives.

The variability of the female urethral pressure profile as determined with the microtransducer technique was studied in a group of healthy nulliparous women according to a standardized methodology. Estimation of the short term reproducibility, as well as investigation of which of several serially recorded urethral pressure profiles can be considered as most representative of the basal condition, was carried out by performing serial urethral pressure profile recordings within the same study session in 12 women. Estimation of the long term reproducibility and investigation of the influence of axial rotation of the transducer membrane on the measurements were carried out in 20 women who were on low dose oral contraceptives. No influence of low dose oral contraceptives on the urethral pressure profile measurements could be detected. When serial recordings were made within the same study session, the lowest values for the urethral closure pressure were generally observed in the 3rd and 4th recordings. The short term and long term reproducibility of urethral pressure profile measurements were generally the same for the measurements in both the supine and the sitting positions. Rotation of the transducer membrane as well as positional changes significantly influenced the urethral pressure profile recordings. The recordings in which the transducer was oriented ventrally generally showed a shorter urethral length and a higher closure pressure than those in which the pressure transducer was oriented laterally or dorsally. These observations as well as the observations made during dynamic testing indicate an asymmetrical distribution of urethral closure forces in healthy nulliparous women.

PIP: The variability of the female urethral pressure profile (UPP) as determined with the microtransducer technique was studied in a group of healthy nulliparous women according to a standardized methodology. Estimation of the shortterm reproducibility, as well as investigation of which of several serially recorded UPP can be considered as most representative of the basal condition, was carried out by performing serial UPP recordings within the same study session in 12 women. Estimation of the longterm reproducibility and investigation of the influence of axial rotation of the transducer membrane on the measurements were carried out in 20 women who were on low dose oral contraceptives. No influence of low dose OCs on the UPP measurements could be detected. When serial recordings were made within the same study session, the lowest values for the urethral closure pressure were generally observed in the 3rd and 4th recordings. The shortterm and longterm reproducibility of UPP measurements were generally the same for the measurements in both the supine and sitting positions. Rotation of the transducer membrane as well as positional changes significantly influenced the UPP recordings. The recordings in which the transducer was oriented ventrally generally showed a shorter urethral length and a higher closure pressure than those in which the pressure transducer was oriented laterally or dorsally. These observations as well as the observations made during dynamic testing indicate an asymmetrical distribution of urethral closure forces in healthy nulliparous women.

The urethral pressure profile in pregnancy and after delivery in healthy nulliparous women.

Simultaneous urethrocystometry by means of a dual microtransducer catheter was performed according to a precise, standardized technique serially at 8, 16, 28, and 36 weeks of pregnancy and at 8 weeks post partum in 43 healthy nulliparous women. The urethral pressure profile at rest and the effect of stress (cough) on the urethral pressure profile during pregnancy and after delivery were measured. At each recording session, blood was obtained for determination of 17 beta-estradiol (E2), progesterone (P), and 17-alpha-hydroxyprogesterone (17-OH-PO). The continence parameters functional urethral length and urethral closure pressure, as well as the urethral closure pressure response to stress, did not change systematically during the course of pregnancy. Engagement of the presenting part at 36 weeks did not influence the urethral pressure profile measurements. Alterations in hormone levels during pregnancy were not correlated with the changes in urethral pressure profile measurements. Both urethral pressure and length parameters in all women who underwent vaginal delivery were notably decreased 8 weeks post partum when compared with early pregnancy values and with values obtained in a group of healthy nulliparous women in the follicular phase of the cycle. The decrease in length parameters was not observed in the six women in whom delivery was by cesarean section. The postpartum changes were not significantly correlated with the duration of the second stage of labor or with the presence or absence of an episiotomy. Also, no relationship with infant birth weight was found. Values of the urethral pressure profile parameters below the median value and defective transmission of pressure over the urethra were observed in almost all women who experienced stress incontinence during pregnancy and/or after delivery. These observations suggest that an inherent weakness of the urethral sphincter mechanism plays a key role in the pathogenesis of stress incontinence.

Urodynamic studies in the normal menstrual cycle: the relationship between hormonal changes during the menstrual cycle and the urethral pressure profile.

The influence of endogenous gonadal steroids on the urethral pressure profile (UPP) was studied in 27 healthy nulliparous women with the normal ovulatory cycles. The UPP and hormonal values were recorded in the follicular phase, at midcycle, and early and late in the luteal phase. Simultaneous urethrocystometry was performed by means of the microtransducer technique, according to a precise standardized methodology. The parameters of the UPP, as defined by the Standardization Committee of the International Continence Society, and the area under the urethral closure pressure curve (integrated pressure) were calculated. Reproducibility of the UPP measurements was evaluated. In addition to a basal body temperature (BBT) chart, serum levels of 17 beta-estradiol (E2), progesterone (P), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin were measured at each study session in order to confirm a normal ovulatory pattern for that cycle and for comparison with the urodynamic parameters. The mean values and standard deviation of the UPP parameters in healthy nulliparous women in the supine and sitting positions are presented. Values of the pressure measurements obtained during one menstrual cycle did not change systemically with the hormonal alterations. At midcycle and early in the luteal phase, however, and anatomic and functional lengths of the urethra were consistently increased over those found in the early follicular and late luteal phases. The data suggest a causal relationship between the changes in serum E2 concentrations and the changes in urethral length.