Tissue Characterization of Puborectalis Muscle From 3-D Ultrasound.

Pelvic floor (PF) muscles have the role of preventing pelvic organ descent. The puborectalis muscle (PRM), which is one of the female PF muscles, can be damaged during child delivery. This damage can potentially cause irreversible muscle trauma and even lead to an avulsion, which is disconnection of the muscle from its insertion point, the pubic bone. Ultrasound imaging allows diagnosis of such trauma based on comparison of geometric features of a damaged muscle with the geometric features of a healthy muscle. Although avulsion, which is considered severe damage, can be diagnosed, microdamage within the muscle itself leading to structural changes cannot be diagnosed by visual inspection through imaging only. Therefore, we developed a quantitative ultrasound tissue characterization method to obtain information on the state of the tissue of the PRM and the presence of microdamage in avulsed PRMs. The muscle was segmented as the region of interest (ROI) and further subdivided into six regions of interest (sub-ROIs). Mean echogenicity, entropy and shape parameter of the statistical distribution of gray values were analyzed on two of these sub-ROIs nearest to the bone. The regions nearest to the bones are also the most likely regions to exhibit damage in case of disconnection or avulsion. This analysis was performed for both the muscle at rest and the muscle in contraction. We found that, for PRMs with unilateral avulsion compared with undamaged PRMs, the mean echogenicity (p = 0.02) and shape parameter (p < 0.01) were higher, whereas the entropy was lower (p < 0.01). This method might be applicable to quantification of PRM damage within the muscle.

Physicians' perspectives on using a patient decision aid in female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: A treatment choice for female stress urinary incontinence (SUI) is preference sensitive for both patients and physicians. Multiple treatment options are available, with none being superior to any other. The decision-making process can be supported by a patient decision aid (PDA). We aimed to assess physicians' perceptions concerning the use of a PDA. METHODS: In a mixed methods study, urologists, gynecologists and general practitioners in the Netherlands were asked to fill out a web-based questionnaire. Questions were based on the Tailored Implementation for Chronic Diseases checklist using the following domains: guideline factors, individual health professional factors, professional interactions, incentives and resources, and capacity for organizational change. Participants were asked to grade statements using a five-point Likert scale and to answer open questions on facilitators of and barriers to implementation of a PDA. Outcomes of statement rating were quantitatively analyzed and thematic analysis was performed on the outcomes regarding facilitators and barriers. RESULTS: The response rate was 11%, with a total of 120 participants completing the questionnaire. Ninety-two of the physicians (77%) would use a PDA in female SUI. Evidence-based and unbiased content, the ability to support shared decision making, and patient empowerment are identified as main facilitators. Barriers are the expected prolonged time investment and the possible difficulty using the PDA in less health-literate patient populations. CONCLUSIONS: The majority of physicians would use a PDA for female SUI. We identified facilitators and barriers that can be used when developing and implementing such a PDA.

Parameters associated with unsuccessful pessary fitting for pelvic organ prolapse up to three months follow-up: a systematic review and meta-analysis.

OBJECTIVES: To clarify which parameters are associated with unsuccessful pessary fitting for pelvic organ prolapse (POP) at up to 3 months follow-up. METHODS: Embase, PubMed and Cochrane CENTRAL library were searched in May 2020. Inclusion criteria were: (1) pessary fitting attempted in women with symptomatic POP; (2) pessary fitting success among the study outcomes with a maximal follow-up of 3 months; (3) baseline parameters compared between successful and unsuccessful group. A meta-analysis was performed using the random effects model. MAIN RESULTS: Twenty-four studies were included in the meta-analysis. Parameters associated with unsuccessful pessary fitting were: age (OR 0.70, 95% CI 0.56-0.86); BMI (OR 1.35, 95% CI 1.08-1.70); menopause (OR 0.65 95% CI 0.47-0.88); de novo stress urinary incontinence (OR 5.59, 95% CI 2.24-13.99); prior surgery, i.e. hysterectomy (OR 1.88, 95% CI 1.48-2.40), POP surgery (OR 2.13, 95% CI 1.34-3.38), pelvic surgery (OR 1.81, 05% CI 1.01-3.26) and incontinence surgery (OR 1.87, 95% CI 1.08-3.25); Colorectal-Anal Distress Inventory-8 scores (OR 1.92, 95% CI 1.22-3.02); solitary predominant posterior compartment POP (OR 1.59, 95% CI 1.08-2.35); total vaginal length (OR 0.56, 95% CI 0.32-0.97); wide introitus (OR 4.85, 95% CI 1.60-14.68); levator ani avulsion (OR 2.47, 95% CI 1.35-4.53) and hiatal area on maximum Valsalva (OR 1.89, 95% CI 1.27-2.80). CONCLUSION: During counselling for pessary treatment a higher risk of failure due to the aforementioned parameters should be discussed and modifiable parameters should be addressed. More research is needed on the association between anatomical parameters and specific reasons for unsuccessful pessary fitting.

Appearance of the levator ani muscle subdivisions on 3D transperineal ultrasound.

BACKGROUND: The levator ani muscle (LAM) consists of different subdivisions, which play a specific role in the pelvic floor mechanics. The aim of this study is to identify and describe the appearance of these subdivisions on 3-Dimensional (3D) transperineal ultrasound (TPUS). To do so, a study designed in three phases was performed in which twenty 3D TPUS scans of vaginally nulliparous women were assessed. The first phase was aimed at getting acquainted with the anatomy of the LAM subdivisions and its appearance on TPUS: relevant literature was consulted, and the TPUS scan of one patient was analyzed to identify the puborectal, iliococcygeal, puboperineal, pubovaginal, and puboanal muscle. In the second phase, the five LAM subdivisions and the pubic bone and external sphincter, used as reference structures, were manually segmented in volume data obtained from five nulliparous women at rest. In the third phase, intra- and inter-observer reproducibility were assessed on twenty TPUS scans by measuring the Dice Similarity Index (DSI). RESULTS: The mean inter-observer and median intra-observer DSI values (with interquartile range) were: puborectal 0.83 (0.13)/0.83 (0.10), puboanal 0.70 (0.16)/0.79 (0.09), iliococcygeal 0.73 (0.14)/0.79 (0.10), puboperineal 0.63 (0.25)/0.75 (0.22), pubovaginal muscle 0.62 (0.22)/0.71 (0.16), and the external sphincter 0.81 (0.12)/0.89 (0.03). CONCLUSION: Our results show that the LAM subdivisions of nulliparous women can be reproducibly identified on 3D TPUS data.

3D Ultrasound Strain Imaging of Puborectalis Muscle.

The female pelvic floor (PF) muscles provide support to the pelvic organs. During delivery, some of these muscles have to stretch up to three times their original length to allow passage of the baby, leading frequently to damage and consequently later-life PF dysfunction (PFD). Three-dimensional (3D) ultrasound (US) imaging can be used to image these muscles and to diagnose the damage by assessing quantitative, geometric and functional information of the muscles through strain imaging. In this study we developed 3D US strain imaging of the PF muscles and explored its application to the puborectalis muscle (PRM), which is one of the major PF muscles.

Stress urinary incontinence after vaginal prolapse repair: development and internal validation of a prediction model with and without the stress test.

OBJECTIVE: To develop a prediction model for stress urinary incontinence (SUI) after vaginal prolapse repair (postoperative stress urinary incontinence [POSUI]) and assess the value of a preoperative stress test. PATIENTS AND METHODS: Secondary analysis of two trials in which women were randomised for prolapse repair with or without a midurethral sling (MUS). The trials included women with (CUPIDO-1, n = 134) and without (CUPIDO-2, n = 225) coexisting SUI. POSUI was defined as bothersome SUI one year after surgery and/or treatment of SUI in the first postoperative year. Logistic regression analysis was used to define a reference model, which was extended with the preoperative stress test. The stress test was performed with and without reduction of the prolapse. Missing values were imputed 20 times, with bootstrap resampling for internal validation of discriminatory ability. RESULTS: Three hundred fifty-six women could be included. POSUI occurred in 17% of the women (n = 61). The reference model included age (<55 years), point Ba of the pelvic organ prolapse quantification system (<-1), vaginal parity (≤3), subjective urinary incontinence, and MUS. The stress test had an odds ratio of 2.4 (95% confidence interval [CI], 1.2-4.6) in the extended model, which increased the optimism-corrected area under the receiver-operating curve from 0.74 to 0.76. The stress test was especially valuable in women with a 10% to 30% POSUI risk, where a stress test substantially impacted the POSUI risk. In more than 50% of the women, the stress test had no additional value in predicting POSUI. CONCLUSION: A preoperative stress test is not valuable for women at low risk of SUI after vaginal prolapse repair.

The predictive value of demonstrable stress incontinence during basic office evaluation and urodynamics in women without symptomatic urinary incontinence undergoing vaginal prolapse surgery.

AIMS: Women with pelvic organ prolapse without symptoms of urinary incontinence (UI) might demonstrate stress urinary incontinence (SUI) with or without prolapse reduction. We aimed to determine the value of demonstrable SUI during basic office evaluation or urodynamics in predicting SUI after vaginal prolapse repair in these women. METHODS: Women included in the CUPIDO trials without bothersome UI or UI more than once a week were eligible if they had undergone prolapse repair without incontinence surgery. The diagnostic and predictive value of demonstrable SUI was studied for postoperative SUI (POSUI). POSUI was defined as bothersome SUI at 1-year follow-up or treatment for SUI in the first postoperative year. RESULTS: In 45% (77/173) of the included women urodynamics was performed. In 19% (32/172) SUI was demonstrated with basic office evaluation, against 29% (22/77) with urodynamics. Nine percent (16/172) developed POSUI, six women underwent surgery for de novo SUI. Women with demonstrable SUI were more at risk to face POSUI: twenty-eight percent versus five percent (Diagnostic Odds Ratio: 7; 95%CI 3-22). Urodynamics predicted one more woman having POSUI, but all women who underwent treatment for de novo SUI showed SUI during basic office evaluation. Test performance did not improved with the adding of urodynamics. CONCLUSIONS: The predictive value of demonstrable SUI in symptomatically continent women undergoing vaginal prolapse repair is limited. Urodynamics added no value. The twenty-eight percent POSUI risk must be balanced against the increased complication risk if a prophylactic midurethral sling is considered.

Vaginal prolapse repair with or without a midurethral sling in women with genital prolapse and occult stress urinary incontinence: a randomized trial.

INTRODUCTION AND HYPOTHESIS: We compared pelvic organ prolapse (POP) repair with and without midurethral sling (MUS) in women with occult stress urinary incontinence (SUI). METHODS: This was a randomized trial conducted by a consortium of 13 teaching hospitals assessing a parallel cohort of continent women with symptomatic stage II or greater POP. Women with occult SUI were randomly assigned to vaginal prolapse repair with or without MUS. Women without occult SUI received POP surgery. Main outcomes were the absence of SUI at the 12-month follow-up based on the Urogenital Distress Inventory and the need for additional treatment for SUI. RESULTS: We evaluated 231 women, of whom 91 randomized as follows: 43 to POP surgery with and 47 without MUS. A greater number of women in the MUS group reported absence of SUI [86 % vs. 48 %; relative risk (RR) 1.79; 95 % confidence interval (CI) 1.29-2.48]. No women in the MUS group received additional treatment for postoperative SUI; six (13 %) in the control group had a secondary MUS. Women with occult SUI reported more urinary symptoms after POP surgery and more often underwent treatment for postoperative SUI than women without occult SUI. CONCLUSIONS: Women with occult SUI had a higher risk of reporting SUI after POP surgery compared with women without occult SUI. Adding a MUS to POP surgery reduced the risk of postoperative SUI and the need for its treatment in women with occult SUI. Of women with occult SUI undergoing POP-only surgery, 13 % needed additional MUS. We found no differences in global impression of improvement and quality of life.

[Survey among gynaecologists and surgeons on rectocele]. / Enquête onder gynaecologen en chirurgen over rectocele.

OBJECTIVE: Provide insight into how gynaecologists and surgeons name, diagnose and treat a rectocele and identify the differences between these two professional groups. DESIGN: Questionnaire survey. METHODS: We sent an online survey with 16 multiple-choice questions to gynaecologists and surgeons from two national working groups. RESULTS: There is no discernible consensus on nomenclature, diagnostics and treatment. Gynaecologists and surgeons each choose their own approach. CONCLUSION: It is in the patient's interest to draw up a joint guideline; however, multidisciplinary cooperation is only possible if gynaecologists and surgeons speak the same language.

Health-related quality of life. The effect of pelvic floor muscle training and midurethral sling surgery: a systematic review.

Stress urinary incontinence (SUI) is a bothersome condition affecting health-related quality of life (HRQoL) to a great extent in women. From a patient's perspective, improving HRQoL is probably equally important as objective cure of SUI. Our objective was to assess the effect of pelvic floor muscle training (PFMT) and midurethral sling surgery on condition-specific HRQoL in women with SUI. A systematic literature search was conducted in the PubMed, Embase, and Cochrane databases. Studies reporting on HRQoL after intervention for SUI or mixed incontinence with a predominant SUI component were selected. Retrieved articles were appraised by all authors regarding participant entry criteria, study design, intervention, questionnaire, objective cure, and HRQoL presentation. There were three articles reporting HRQoL after PFMT and 11 after midurethral sling surgery. Improvement in HRQoL seemed higher after midurethral sling surgery compared with PFMT. However, methods of HRQoL assessment varied widely, limiting the possibility of comparison and interpretation between studies.

Effects of vaginal prolapse surgery on sexuality in women and men; results from a RCT on repair with and without mesh.

INTRODUCTION: In pelvic organ prolapse (POP) repair, the use of synthetic mesh is not only increasing but also a subject of discussion. The focus shifts from anatomical toward functional outcome, with sexual function being an important parameter. One of the concerns with mesh usage in POP surgery is the possible negative effect on sexual function. AIM: To compare and assess sexual function in women and men after primary cystocele repair with or without trocar-guided transobturator mesh. METHODS: One hundred twenty-five women with a symptomatic cystocele stage ≥ II were included in this multicenter randomized controlled trial and assessed at baseline and 6-month follow-up. MAIN OUTCOME MEASURES: Female sexual function was measured by the Female Sexual Function Index (FSFI) and male sexual function by the Male Sexual Health Questionnaire. A subgroup analysis of women with a participating partner was performed. RESULTS: In the mesh group, 54/59 women vs. 53/62 in the anterior colporrhaphy group participated. In men, 29 vs. 30 participated. After surgery, FSFI scores were comparable for both treatment groups. However, within group analysis showed significant improvement on the domains pain (effect size = 0.5), lubrication (effect size = 0.4), and overall satisfaction (effect size = 0.5) in the colporrhaphy group. This improvement was not observed in the mesh group. A subgroup of women with a participating partner reported significantly higher baseline domain scores as compared with other women and did not report a significant improvement of sexual functioning irrespective of treatment allocation. Worsening of baseline sexual function was reported by 43% of women in the mesh group compared with 18% in anterior colporrhaphy group (P = 0.05). Male sexual functioning did not change in either group. CONCLUSIONS: Women after an anterior colporrhaphy report a significant and clinically relevant improvement of their sexual functioning, whereas women after a mesh procedure did not.

Predicting the development of stress urinary incontinence 3 years after hysterectomy.

INTRODUCTION AND HYPOTHESIS: We aimed to develop a prediction rule to predict the individual risk to develop stress urinary incontinence (SUI) after hysterectomy. METHODS: Prospective observational study with 3-year follow-up among women who underwent abdominal or vaginal hysterectomy for benign conditions, excluding vaginal prolapse, and who did not report SUI before surgery (n = 183). The presence of SUI was assessed using a validated questionnaire. RESULTS: Significant prognostic factors for de novo SUI were BMI (OR 1.1 per kg/m(2), 95% CI 1.0-1.2), younger age at time of hysterectomy (OR 0.9 per year, 95% CI 0.8-1.0) and vaginal hysterectomy (OR 2.3, 95% CI 1.0-5.2). Using these variables, we developed the following rule to predict the risk of developing SUI: 32 + BMI-age + (7.5 × route of surgery). CONCLUSIONS: We defined a prediction rule that can be used to counsel patients about their individual risk on developing SUI following hysterectomy.

The effect of prolapse surgery on vaginal sensibility.

INTRODUCTION: Prolapse surgery has been shown to have major impact on sexual function. Since prolapse surgery not only influences psychological factors but might also influence physiological conditions such as vaginal innervation, there is a need for objective outcome measurements to better understand the effects of prolapse surgery on sexual function. AIMS: To assess the effects of prolapse surgery with or without stress incontinence surgery on vaginal sensibility and to assess the relationship between vaginal wall sensibility and sexual well-being. METHODS: This study was performed parallel to a randomized controlled trial comparing vaginal and abdominal prolapse surgery with or without incontinence surgery in women with uterine prolapse stage 2 or more. MAIN OUTCOME MEASURES: Vaginal wall sensibility was defined as mean sensation threshold to electrical stimulation of the vaginal wall at four standardized places, measured before and 6 months after surgery. Higher sensation thresholds postsurgery relative to presurgery indicate diminished vaginal wall sensibility. Sexual function was assessed at the same time points using a questionnaire. RESULTS: Data on vaginal wall sensibility were obtained from 65 patients. The sensibility of the distal posterior (P = 0.02) and distal anterior (P = 0.10) vaginal wall decreased after vaginal surgery compared to abdominal surgery. Abdominal prolapse surgery with incontinence surgery decreased sensibility of the distal part of the anterior vaginal wall significantly more than abdominal prolapse surgery only (P = 0.01). Before surgery, vaginal wall sensibility was lower in women who reported vaginal dryness or anorgasmia. The presence of genital pain was associated with higher vaginal wall sensibility. Postoperative vaginal wall sensibility was similar in women with and without sexual problems. CONCLUSION: Vaginal prolapse surgery as well as abdominal prolapse surgery with additional incontinence surgery resulted in decreased vaginal wall sensibility. This pilot study shows no influence of the decreased vaginal wall sensibility on sexual well-being. Larger studies are needed to better understand the association between changes in vaginal wall sensibility and changes in sexual well-being.

Bacterial colonisation of collagen-coated polypropylene vaginal mesh: are additional intraoperative sterility procedures useful?

INTRODUCTION AND HYPOTHESIS: The use of vaginally implanted polypropylene meshes in the treatment of prolapse is becoming increasingly popular. We set out to detect how often bacterial colonisation of the mesh occurs and if the intraoperative sterility procedures that are applied matter. METHODS: In 64 consecutive women, bacterial colonisation was compared between two intraoperative sterility procedures. Culture swabs of the core mesh were taken during surgery, and the mesh arms removed at the end of surgery were cultured separately. RESULTS: Sixty-seven implants were cultured. In 56 (83.6%) implants, a positive culture with vaginal bacteria was found with very low bacterial density (<10(3 )colony-forming units). No significant differences in bacterial species, density, clinical infection and erosion (two anterior and one posterior) were found between the two intraoperative sterility methods. CONCLUSIONS: Colonisation of vaginally implanted mesh occurs frequently but in low bacterial densities, irrespective of the intraoperative sterility procedure used.

Protocol for the value of urodynamics prior to stress incontinence surgery (VUSIS) study: a multicenter randomized controlled trial to assess the cost effectiveness of urodynamics in women with symptoms of stress urinary incontinence in whom surgical treatment is considered.

BACKGROUND: Stress urinary incontinence (SUI) is a common problem. In the Netherlands, yearly 64.000 new patients, of whom 96% are women, consult their general practitioner because of urinary incontinence. Approximately 7500 urodynamic evaluations and approximately 5000 operations for SUI are performed every year. In all major national and international guidelines from both gynaecological and urological scientific societies, it is advised to perform urodynamics prior to invasive treatment for SUI, but neither its effectiveness nor its cost-effectiveness has been assessed in a randomized setting. The Value of Urodynamics prior to Stress Incontinence Surgery (VUSIS) study evaluates the positive and negative effects with regard to outcome, as well as the costs of urodynamics, in women with symptoms of SUI in whom surgical treatment is considered. METHODS/DESIGN: A multicentre diagnostic cohort study will be performed with an embedded randomized controlled trial among women presenting with symptoms of (predominant) SUI. Urinary incontinence has to be demonstrated on clinical examination and/or voiding diary. Physiotherapy must have failed and surgical treatment needs to be under consideration. Patients will be excluded in case of previous incontinence surgery, in case of pelvic organ prolapse more than 1 centimeter beyond the hymen and/or in case of residual bladder volume of more than 150 milliliter on ultrasound or catheterisation. Patients with discordant findings between the diagnosis based on urodynamic investigation and the diagnosis based on their history, clinical examination and/or micturition diary will be randomized to operative therapy or individually tailored therapy based on all available information. Patients will be followed for two years after treatment by their attending urologist or gynaecologist, in combination with the completion of questionnaires. Six hundred female patients will be recruited for registration from approximately twenty-seven hospitals in the Netherlands. We aspect that one hundred and two women with discordant findings will be randomized. The primary outcome of this study is clinical improvement of incontinence as measured with the validated Dutch version of the Urinary Distress Inventory (UDI). Secondary outcomes of this study include costs, cure of incontinence as measured by voiding diary parameters, complications related to the intervention, re-interventions, and generic quality of life changes. TRIAL REGISTRATION: Clinical Trials NCT00814749.

Vaginal surgery for uterine descent; which options do we have? A review of the literature.

Several vaginal procedures are available for treating uterine descent. Vaginal hysterectomy is usually the surgeon's first choice. In this literature review, complications, anatomical and symptomatic outcomes, and quality of life after vaginal hysterectomy, sacrospinous hysteropexy, the Manchester procedure, and posterior intravaginal slingplasty are described. All procedures had low complication rates, except posterior intravaginal slingplasty, with a tape erosion rate of 0-21%. Minimal anatomical success rates regarding apical support ranged from 85% and 93% in favor of the Manchester procedure. Data on symptomatic cure and quality of life are scarce. In studies comparing vaginal hysterectomy with sacrospinous hysteropexy or the Manchester procedure, vaginal hysterectomy had higher morbidity. Because no randomized, controlled trials have been performed comparing these surgical techniques, we can not conclude that one of the procedures prevails. However, one can conclude from the literature that vaginal hysterectomy is not the logical first choice.

Hysterectomy does not cause constipation.

PURPOSE: This study was designed to evaluate the risk on development and persistence of constipation after hysterectomy. METHODS: We conducted a prospective, observational, multicenter study with three-year follow-up in 13 teaching and nonteaching hospitals in The Netherlands. A total of 413 females who underwent hysterectomy for benign disease other than symptomatic uterine prolapse were included. All patients underwent vaginal hysterectomy, subtotal abdominal hysterectomy, or total abdominal hysterectomy. A validated disease-specific quality-of-life questionnaire was completed before and three years after surgery to assess the presence of constipation. RESULTS: Of the 413 included patients, 344 (83 percent) responded at three-year follow-up. Constipation had developed in 7 of 309 patients (2 percent) without constipation before surgery and persisted in 16 of 35 patients (46 percent) with constipation before surgery. Preservation of the cervix seemed to be associated with an increased risk of the development of constipation (relative risk, 6.6; 95 percent confidence interval, 1.3-33.3; P = 0.02). Statistically significant risk factors for the persistence of constipation could not be identified. CONCLUSIONS: Hysterectomy does not seem to cause constipation. In nearly half of the patients reporting constipation before hysterectomy, this symptom will disappear.

Pregnancy-related pelvic girdle pain in the Netherlands.

OBJECTIVE: In this longitudinal cohort study, we assessed the prevalence, associated delivery-related and psychosocial factors and consequences of self-reported pelvic girdle pain during and after pregnancy in the Netherlands. METHODS: A total of 412 women, expecting their first child, answered questionnaires regarding back and pelvic girdle pain, habits, and biomedical, sociodemographic and psychosocial factors, at 12 and 36 weeks gestation, and 3 and 12 months after delivery. In addition, birth records were obtained. Possible associations were studied using non-parametric tests. RESULTS: The prevalence of self-reported pelvic girdle pain was at its peak in late pregnancy (7.3%). One out of 7 women suffering from pelvic girdle pain at 36 weeks gestation, and almost half of the women suffering from pelvic girdle pain 3 months after delivery, continued to report symptoms 1 year after delivery. Women reporting pelvic girdle pain are less mobile than women without pain or women with back pain only, and more frequently have to use a wheelchair or crutches. No association was found between obstetric factors and pelvic girdle pain. Women with pelvic girdle pain report more co-morbidity and depressive symptoms. RECOMMENDATIONS: Normal obstetric procedures can be followed in women reporting pregnancy-related pelvic girdle pain. Prognosis is generally good, however, women reporting pelvic girdle pain 3 months after delivery need extra consideration. Attention needs to be given to psychosocial factors, in particular depressive symptoms.

The effect of vaginal and cesarean delivery on lower urinary tract symptoms: what makes the difference?

A prospective cohort study was undertaken to evaluate the effect of pregnancy and childbirth in nulliparous pregnant women. The focus of this paper is on the difference in the prevalences and risk factors for lower urinary tract symptoms (LUTS) between woman who delivered vaginally or by cesarean and secondly the effect of LUTS on the quality of life between these two groups was analyzed. Included were 344 nulliparous pregnant women who completed four questionnaires with the Urogenital Distress Inventory and the Incontinence Impact Questionnaire (IIQ). Two groups were formed: vaginal delivery group (VD), which included spontaneous vaginal delivery and an instrumental vaginal delivery and cesarean delivery group (CD). No statistical significant differences were found in the prevalences of LUTS during pregnancy between the two groups. Three months after childbirth, urgency and urge urinary incontinence (UUI) are less prevalent in the CD group, but no statistical difference was found 1 year postpartum. Stress incontinence was significantly more prevalent in the VD group at 3 and 12 months postpartum. The presence of stress urinary incontinence (SUI) in early pregnancy is predictive for SUI both in the VD as in CD group. A woman who underwent a CD and had SUI in early pregnancy had an 18 times higher risk of having SUI in year postpartum. Women were more embarrassed by urinary frequency after a VD. After a CD, 9% experienced urge urinary incontinence. Urge incontinence affected the emotional functioning more after a cesarean, but the domain scores on the IIQ were low, indicating a minor restriction in lifestyle. In conclusion, after childbirth, SUI was significantly more prevalent in the group who delivered vaginally. Besides a vaginal delivery, we found both in the VD and in the CD group that the presence of SUI in early pregnancy increased the risk for SUI 1 year after childbirth. Further research is necessary to evaluate the effect of SUI in early pregnancy on SUI later in life. Women were more embarrassed by urinary frequency after a vaginal delivery. UUI after a CD compared to a vaginal birth limited the women more emotionally; no difference was found for the effect of SUI on the quality of life between the two groups.

Bothersome lower urinary tract symptoms 1 year after first delivery: prevalence and the effect of childbirth.

OBJECTIVE: To assess the severity of both stress urinary incontinence (SUI) and overactive bladder (OAB) symptoms during and after the first pregnancy, using a self-reported health-related quality-of-life questionnaire, and to assess the effect of pregnancy and childbirth on bothersome lower urinary tract symptoms (LUTS) persisting at 1 year after the first childbirth. PATIENTS AND METHODS: In a prospective cohort study, 344 women completed four self-reported questionnaires. Urogenital symptoms were assessed with the Urogenital Distress Inventory (UDI), assessing if a urogenital symptom is present and the amount of bother it causes, measured on a 4-point Likert scale, i.e. 'not at all', 'slightly', 'moderately' and 'greatly bothered'. Bothersome LUTS were defined as reporting moderate or great bother from the symptom, and as not bothersome if it was absent or present with none or only a slight degree of self-reported bother. In the analysis we used three of the five subscales from the UDI; UI, OAB and obstructive voiding, where each subscale has a range of 0 (no symptom) to 100 (all symptoms present with the highest degree of bother). RESULTS: Of the 344 women, 83 (24.2%) reported having a moderate to greatly bothersome frequency symptom at 36 weeks of gestation. After childbirth there was a statistically significant decline in the prevalence of bothersome frequency to 38 (9.6%) women (P < 0.001). Bothersome SUI was present in 53 (15.4%) women at 36 weeks of gestation, and in 36 (10.5%) at 1 year after childbirth. Fifty-eight (16.9%) women reported having moderate to greatly bothersome urge UI (UUI) and at 1 year after childbirth, 51 (14.8%) were still bothered by it. After univariate and multivariate analysis, the predictive factors for the presence of bothersome SUI were greater maternal age (32.5 vs 30.3 years old at delivery) and the presence of bothersome SUI at 12 weeks of gestation. Bothersome UUI was significantly associated with a lower educational level (odds ratio 0.08, 95% confidence interval 0.02-0.36). Women after a Caesarean delivery had more bothersome UUI and women after a spontaneous vaginal delivery developed more bothersome SUI (neither statistically significant, possibly because there were too few samples). During pregnancy, all UDI subscale scores increased significantly and after childbirth all scores decreased significantly vs 36 weeks of gestation. However, the score on the UI subscale remained significantly higher at 1 year after birth than at 12 weeks of gestation, whereas the scores on the OAB and obstructive voiding subscales were lower at 1 year after birth than at 12 weeks of gestation. Nevertheless, the scores for UI and obstructive voiding were low, indicating little bother. CONCLUSION: Most women are not bothered by their LUTS after their first delivery. As the prevalence of bothersome symptoms was highest at 36 weeks of gestation, they are probably part of a normal pregnancy. However, OAB symptoms can be perceived as bothersome. Physiotherapy and bladder training can be offered to women with bothersome LUTS. Bothersome SUI in early pregnancy and a greater maternal age were predictive of bothersome SUI at 1 year after first childbirth. A Caesarean delivery seemed to be protective for bothersome SUI at 1 year after birth, but bothersome UUI was more prevalent after a Caesarean than a vaginal delivery. More research with a larger sample is needed to allow definite statements about the effect of the mode of delivery and bothersome UI symptoms.