Transvaginal Paravaginal Native Tissue Anterior Repair Technique: Initial Outcomes.

OBJECTIVE: To present the surgical technique and initial outcomes for a novel lattice-work technique, developed to increase the durability of the native tissue repair. METHODS/ MATERIALS: All patients undergoing transvaginal anterior prolapse repair with a single surgeon with at least 30 days of follow-up were prospectively enrolled starting in 2017. All patients received the same repair (Fig. 1). 2.0 polydioxanone (PDS) sutures are placed at the level of the obturator fascia/arcus tendineus distally and proximally on each side. The midline anterior colporrhaphy is performed with 4 2.0 PDS sutures which are then intertwined with the obturator sutures and tied to form a lattice of sutures to reinforce the cystocele repair and elevate the central defect repair laterally. Clinic notes, objective physical exam, and standardized subjective patient questionnaires (Pelvic Floor Disorders Inventory) were evaluated for patient outcomes. Recurrence was defined anatomically (Pelvic organ prolapse-Q Ba ≥-1) and subjectively (bothersome vaginal bulge). RESULTS: There were 109 patients enrolled with a mean follow-up time was 12 months. Over the follow-up period, there were 12 anatomic recurrences (11%). This was not associated with concomitant apical or posterior repair. Mean time to recurrence was 13.9 months. There were no intraoperative complications. Transient urinary retention was the most notable complication (19%, managed conservatively). Rate of de novo stress urinary incontinence was low at 4%. CONCLUSION: This novel lattice-work technique is simple to perform and has excellent short term anatomic outcomes. Transient postoperative retention was observed; however, all cases self-resolved. Further follow-up is ongoing to characterize the long-term durability of this repair.

Anterior Colporrhaphy With and Without Dermal Allograft: A Randomized Control Trial With Long-Term Follow-Up.

OBJECTIVE: The objective of this study was to determine whether anterior colporrhaphy plus insertion of anterior dermal allograft reduces anterior prolapse recurrence at 1 and 7 to 10 years postoperatively compared with anterior colporrhaphy alone. METHODS: We present a nonblinded randomized controlled trial with 1- and 7- to 10-year follow-up. Subjects were randomized between 2005 and 2008 to anterior colporrhaphy or ultralateral anterior colporrhaphy plus insertion of a dermal allograft spanning the anterior compartment between the arcus tendineus fascia pelvis on each side. Eligible subjects had anterior prolapse to the hymen or beyond, were bothered by their prolapse, and were planning to undergo surgical correction. Subjects completed a pelvic organ prolapse quantification system (POPQ) examination and Pelvic Floor Distress Inventory (PFDI)/PFDI-20 before surgery; a POPQ, PFDI, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire at 1 year postoperatively; and a POPQ, PFDI-20, Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, Revised, and Patient-reported Global Impression of Improvement Inventory at 7 to 10 years postoperatively. Our primary outcome was anatomic anterior prolapse recurrence at 1 or 7 to 10 years defined as Aa or Ba greater than or equal to -1. Our secondary outcome was a composite score of anterior prolapse recurrence at 1 or 7 to 10 years defined as anatomic recurrence (Aa or Ba ≥ 0), retreatment for cystocele, or answering yes to PFDI-20 question 3 (subjective report of vaginal bulge). RESULTS: A total of 114 subjects were randomized, 70 to anterior colporrhaphy and 44 to anterior colporrhaphy plus dermal allograft. About 92% of subjects underwent concomitant apical suspension, 98% in the graft group and 89% in the nongraft group. Eighty-nine subjects (32 graft [73%], 57 nongraft [81%]) returned for 1-year follow-up. Fifty-three patients (19 graft [48%], 34 nongraft [49%]) returned for 7- to 10-year follow-up. The primary outcome was met by 8 (18%) graft and 22 (31%) nongraft subjects at 1 year postoperatively (P = 0.26) and by 10 (23%) graft and 24 (34%) nongraft subjects at 7 to 10 years postoperatively (P = 0.37). The secondary outcome was met by 8 (18%) graft and 15 (21%) nongraft subjects at 1 year postoperatively (P = 0.74) and by 13 (30%) graft and 21 (30.0%) nongraft subjects at 7 to 10 years postoperatively (P = 0.99). CONCLUSIONS: We cannot conclude whether there is a difference in anterior recurrence for anterior colporrhaphy with and without dermal allograft and do not recommend changes in clinical practice based on these results.

The Manchester repair: an instructional video.

OBJECTIVE: The Manchester repair, developed in the UK by Donald, described in 1908, and later modified by Fothergill, is a well-studied and proven surgical treatment for uterovaginal prolapse when uterine preservation is desired. This operation is currently not widely performed in parts of the world (USA) but is becoming increasing popular in Europe. The objective of this video is to demonstrate our surgical technique and recommendations for successful completion of the procedure. METHODS: This patient is a 39-year-old woman with two previous vaginal deliveries who presented with a 1-year history of vaginal protrusion. She had no urinary or bowel symptoms. On examination, she had a grade 2 cystocele and uterine descent. She desired surgical management of her uterovaginal prolapse but wished to retain her uterus. The procedure involves mobilizing the vagina and bladder off the cervix and uterosacral cardinal ligament complex anteriorly and laterally. The cervix is then amputated. The ligaments are clamped, cut, and ligated and attached to the anterior cervical remnant with an overlapping suture. This pulls the cervix backward into the pelvis and results in anteversion of the uterus. A posterior and then anterior Sturmdorf suture is used to reconstruct the cervix by covering the amputated cervix with vaginal mucosa. CONCLUSION: The Manchester repair is an operation worth considering in patients where preservation of the uterus is desired. It uses native tissue and has a low complication rate and good long-term results.

Etiopathogenic, therapeutic and histopathological aspects upon the anterior vaginal wall prolapse.

The pelvine organ prolapse (POP) is a condition affecting million of women, with a major impact upon the social and professional life of the patients. According to various studies, it affects approximately 40% of the women aged over 50 years. About 10% of women with POP require a surgical procedure for POP or urinary incontinence. Our study comprised a number of 14 patients, aged between 55 and 70 years, hospitalized and treated in the Clinic of Urology within the Emergency County Hospital of Craiova, Romania, between 2011 and 2013, for second-degree cystocele. Of these, 11 (78.57%) patients had more than two natural deliveries, 10 suffered more than three abortions, and eight (57.14%) women suffered from obesity. The increase of abdominal pressure, induced by chronic coughing, constipation or hard physical work, was identified in more patients. Thus, six (42.8%) patients presented chronic bronchitis, four (28.57%) patients were smokers, eight (57.14%) patients presented chronic constipation, and 10 (71.42%) patients stated that they had performed hard physical work. The presence of effort urinary incontinence, associated to the cystocele, was found in eight (57.14%) cases. The surgical intervention consisted in the performance of a direct cystopexia with a synthetic tent, placed in a transobturatory way, in a "tension free" manner (Perigee System). The post-operatory evolution was a good one; the results after six months showed that 12 (85.71%) women were cured, two (14.29%) cases of cystocele relapsed, while in two patients there maintained the effort urinary incontinence. The histopathological examination of the anterior vaginal wall fragments, harvested during the surgical intervention, showed the presence of a chronic inflammatory infiltrate in the lamina propria of the uterine mucosa, which may cause the post-operatory relapses. We consider that the reduction of the inflammatory process through the administration of anti-inflammatory drugs could reduce the POP onset and progress.

Levator avulsion is not associated with symptom bother of female pelvic organ prolapse.

PURPOSE: Both congenital and traumatic factors are likely to play a role in the etiology of female pelvic organ prolapse. We hypothesized that congenital prolapse may be less bothersome than traumatic prolapse related to vaginal childbirth. METHODS: This is a retrospective study using 482 archived data sets of patients seen for urodynamic testing. Patients had an interview, clinical and sonographic examination using 4D translabial ultrasound. Prolapse bother was determined by visual analog scale (VAS). RESULTS: A total of 463 patients were seen, of which 254 (55 %) suffered from symptoms of prolapse. The median bother attributable to these symptoms on VAS was 2 (0-10). Clinically significant prolapse was found in 81 % (cystocele 63 %, uterine prolapse 13 %, enterocele 5 %, rectocele 52 %). Evidence of major childbirth-related trauma, i.e., avulsion, was diagnosed in 118 (26 %), and it was bilateral in 9 %. On univariate analysis, clinical stage, maximal prolapse on ultrasound, levator avulsion, vaginal parity and hiatal area were significantly associated with prolapse bother. In a multivariate linear regression analysis, only prolapse extent remained a significant predictor (P < 0.0001), implying that evidence of traumatic prolapse etiology had no significant influence on prolapse bother. CONCLUSION: The presence of levator avulsion did not influence the degree of bother resulting from pelvic organ prolapse symptoms. Hence, increased prolapse bother does not seem to be associated with evidence of traumatic prolapse etiology.

Can we identify changes in fascial paravaginal supports after childbirth?

BACKGROUND: Defects of anterior vaginal wall fascia are generally assumed to be factors in the aetiology of cystocele. However, to date, there is very little information on diagnosis by imaging. AIM: To document the appearance of vaginal fornices before and after childbirth using 4D ultrasound volume data sets as an aid in diagnosing paravaginal defects of the anterior vaginal wall. MATERIALS AND METHODS: This study was performed by re-analysing data sets obtained in a previously published study involving ante- and postpartum pelvic floor assessment by ultrasound. Two hundred and two nulliparous women had been seen at a mean gestation of 37.2 weeks at two tertiary hospitals. One hundred and sixty-three returned 3 months postpartum. All the participants underwent an interview and 4D translabial ultrasound at both antepartum and postpartum appointments. The integrity of vaginal fornices and levator ani was assessed by tomographic ultrasound. RESULTS: Vaginal fornices were assessed in both ante- and postnatal volumes, and loss of forniceal tenting was found in 85 patients (52%). On average, seven slices were affected (range, 1-16). On multivariate analysis, controlling for potential confounders, including partial/complete avulsion, loss of forniceal tenting remained independently associated with increased cystocele descent (P = 0.005). CONCLUSIONS: Vaginal childbirth is associated with loss of tenting of the vaginal fornices, independent of levator trauma, and also with impaired anterior vaginal wall support. This evidence suggests the existence of paravaginal defects and may imply a role for such defects in the causation of anterior vaginal wall prolapse.

Large rectovaginal fistula due to a cube pessary despite routine follow-up; but what is 'routine'?

Vaginal pessaries are generally considered a safe and effective form of management for pelvic organ prolapse. Serious complications such as rectovaginal fistula can develop with or without regular follow-up. This case report describes the rapid development over a 10-week period of a large rectovaginal fistula in a 75-year-old woman, despite routine follow-up and replacement of her cube pessary. Currently, there is a lack of evidence-based guidelines for pessary care and, in particular, the frequency of pessary replacement. Intervals for pessary replacements vary greatly and are often based on the manufacturer's recommendations. This case highlights the rapidity at which serious complications can develop and also represents the first reported case of a cube pessary-induced rectovaginal fistula.

The length of anterior vaginal wall exposed to external pressure on maximal straining MRI: relationship to urogenital hiatus diameter, and apical and bladder location.

INTRODUCTION AND HYPOTHESIS: In cystoceles, the distal anterior vaginal wall (AVW) bulges out through the introitus and is no longer in contact with the posterior vaginal wall or perineal body, exposing the pressure differential between intra-abdominal pressure and atmospheric pressure. The goal of this study is to quantify the length of the exposed vaginal wall length and to investigate its relationship with other factors associated with the AVW support, such as most dependent bladder location, apical location, and hiatus diameter, demonstrating its key role in cystocele formation. METHODS: Fifty women were selected to represent a full spectrum of AVW support. Each underwent supine, dynamic MR imaging. Most dependent bladder location and apical location were measured relative to the average normal position on the mid-sagittal plane using the Pelvic Inclination Correction System . The length of the exposed AVW and the hiatus diameter were measured as well. The relationship between exposed AVW and most dependent bladder location, apical location, and hiatus diameter were examined. RESULTS: A bilinear relationship has been observed between exposed vaginal wall length and most dependent bladder location (R(2) = 0.91, P < 0.001). When the bladder descents up to the inflection point (about 4.4 cm away from its normal position), there is little change in the exposed AVW length. With further descent, the exposed vaginal wall length increases significantly, with a 2 cm increase in exposed AVW length for every additional 1 cm of drop bladder location. A similar but weaker bilinear relationship exists between exposed AVW and apical location. Exposed vaginal wall length is also highly correlated with hiatus diameter (R(2) = 0.85, P < 0.001). CONCLUSION: A bilinear relationship exists between exposed vaginal wall length and most dependent bladder location and apical location. It is when the bladder descent is beyond the inflection point that exposed vaginal wall length increases significantly.

A randomized controlled trial comparing anatomical and functional outcome between vaginal colposuspension and transvaginal mesh.

INTRODUCTION AND HYPOTHESIS: Our aim was to compare anatomical and functional outcome between vaginal colposuspension and transvaginal mesh. METHODS: This was a prospective randomized controlled trial in a teaching hospital. Sixty-eight women with stage ≥3 anterior vaginal wall prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system were assessed, randomized, and analyzed. Patients were randomized to anterior colporrhaphy with vaginal colposuspension (n = 35) or transvaginal mesh (n = 33). Primary outcome was objective cure rate of the anterior vaginal wall, defined as POP-Q ≤1 at 2 years. Secondary outcomes were functional results, quality-of-life (QoL) scores, mesh-related morbidity, and onset of urinary incontinence. RESULTS: The anatomical result for point Ba was significantly better at 2 years in the mesh group (-2.8 cm) than in the colposuspension group (-2.4 cm) (p = 0.02). Concerning POP-Q stages, the anatomical success rate at 2 years was 84.4 % for colposuspension and 100 % for mesh (p = 0.05). There were 5 anatomic recurrences (15.6 %) in the colposuspension group. The erosion rate was 6 % (n = 2). No significant difference was noted regarding minor complications. Analysis of QoL questionnaires showed overall improvement in both groups, with no significant difference between them. CONCLUSIONS: The vaginal colposuspension technique of anterior vaginal wall prolapse repair gave good anatomical and functional results at 2 years. Transobturator vaginal mesh gave better 2-year anatomical results than vaginal colposuspension, with overall improvement in QoL in both groups.

Outcomes of robotic sacrocolpopexy using barbed delayed absorbable sutures.

STUDY OBJECTIVE: To evaluate 1-year outcomes of robotic sacrocolpopexy (RSC) for pelvic organ prolapse using barbed delayed absorbable sutures. DESIGN: Retrospective cohort study (Class II-3). SETTINGS: University-based hospital in Southeast Texas. PATIENTS: Patients with symptomatic apical pelvic organ prolapse who underwent RSC using barbed delayed absorbable sutures between January 2011 and August 2012. Patients were examined postoperatively at least twice (after 6 weeks and 1 year). INTERVENTIONS: RSC procedure. MEASUREMENTS AND MAIN RESULTS: The study included a total of 20 patients, of them 15 had grades 3 or 4 whereas 5 had grade 2 apical defects according to the Baden-Walker classification system. Fourteen patients (70%) underwent concomitant hysterectomy while 9 (45%) underwent concomitant anti-incontinence surgery. Mesh suturing times were 46.9 ± 12.6 and 20.5 ± 9.3 minutes in the first 10 versus the last 10 cases, respectively (p < .001). The mean follow-up duration was 17.3 months (range, 12-24 months). There were no recurrences of apical defects or mesh/suture exposure/erosion. However, 1 patient developed a grade 2 cystocele, and another developed new-onset urinary incontinence, both after 1 year. A third patient's urine leakage did not improve postoperatively. Lastly, a fourth patient developed port site incisional hernia and underwent repair 5 months later. CONCLUSION: Our study suggests that barbed delayed absorbable sutures are safe and effective in RCS procedures over 1 year. Larger, comparative, and randomized trials are recommended for definitive conclusions.

Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement?

OBJECTIVE: Levator avulsion has been shown to be a predictor of cystocele recurrence following anterior colporrhaphy. The aim of this study was to determine if levator avulsion is a risk factor for prolapse recurrence following anterior colporrhaphy with mesh. METHODS: This was a retrospective analysis of data obtained from three surgical audits for subjective and objective outcomes following anterior colporrhaphy with mesh. Recurrence was defined as cystocele ≥ Stage 2 on the prolapse quantification system of the International Continence Society; symptoms of vaginal lump/bulge; or cystocele on ultrasound, defined as maximum bladder descent to ≥ 10 mm below the symphysis pubis. Levator avulsion was diagnosed using tomographic ultrasound imaging. RESULTS: Two hundred and nine patients were followed up at a mean of 2.2 years (range, 3 months to 5.6 years) after anterior vaginal mesh placement. 24% (51/209) had recurrent prolapse symptoms, 33% (68/209) clinical cystocele recurrence ≥ Stage 2, and 26% (54/209) a recurrent cystocele on ultrasound. Twenty-eight out of 80 (35%) women with levator avulsion had significant sonographic cystocele recurrence (odds ratio (OR), 2.24 (95% confidence interval (CI), 1.13-4.43)). This finding was confirmed after adjusting for potential predictors of prolapse recurrence on multivariate logistic regression (OR, 2.13 (95% CI, 1.04-4.39); P = 0.04). CONCLUSION: Levator avulsion doubles the risk of cystocele recurrence after anterior colporrhaphy with transobturator mesh.

Prevalence of and risk factors for pelvic organ prolapse and lower urinary tract symptoms among women in rural Nepal.

OBJECTIVE: To evaluate the prevalence and associated risk factors of pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTS) among women seeking healthcare services in 3 discrete rural areas in Nepal. METHODS: A cross-sectional study was conducted using a Nepalese-specific questionnaire to obtain demographic and personal information. Urinary symptoms were examined using the Urogenital Distress Inventory Short form questionnaire, while POP severity was staged according to the POP-Q system. The χ(2) test and multivariate logistic regression analysis were used to determine POP risk factors. RESULTS: Of the 174 women included in the analysis, 106 (60.9%) had stage II POP or greater. In all, 93 women (53.4%) had cystocele, 63 (36.2%) had rectocele, and 37 (21.3%) had uterine prolapse. Univariate analysis identified high parity; young age at first delivery; menopause; squatting or standing position during delivery; and early return to work after delivery as risk factors for POP. Multivariate logistic regression revealed that delivery in a lying position presented a lower risk for cystocele than squatting or standing (odds ratio 0.34; P<0.01). CONCLUSION: Both LUTS and POP are common among women in rural Nepal. Cystocele is the most frequent, advanced, and symptomatic form of POP observed in this population.

Urinary retention after orthotopic neobladder substitution in females.

PURPOSE: Urinary retention is a common complication after orthotopic neobladder urinary diversion. We reviewed a case series of women who underwent neobladder creation and discuss anatomical findings, and urinary retention etiology and prevention. MATERIALS AND METHODS: We retrospectively reviewed the records of all orthotopic neobladder urinary diversions in female patients performed at our institution from 1999 through 2010. We abstracted baseline clinical and demographic characteristics, operative information, and postoperative clinical, urodynamic, imaging and secondary procedure followup. We defined urinary retention as the need for intermittent catheterization. RESULTS: We identified 21 female patients who underwent neobladder diversion. Median age at cystectomy was 62 years (range 43 to 77). Median followup was 3 years (range 3 to 138 months). Of the patients 14 underwent ileocolic diversion, 6 underwent Studer ileal diversion and 1 underwent preservation of a right colon augmentation. All patients underwent prior or concurrent hysterectomy. In 2 patients with a history of genitourinary tuberculosis neobladder-vaginal fistulas developed postoperatively and they were excluded from analysis. Of the 19 female patients with a neobladder included in analysis 7 (36.8%) experienced urinary retention requiring clean intermittent catheterization. Associated abnormalities included neocystocele formation in 6 cases, anastomotic stricture in 1 and progressive neurological disease in 1. Upon straining the average neobladder descent was approximately 2 cm and the average change in the neocystourethral angle in patients with neocystoceles was 18 degrees. Of the patients 11 (57.9%) had a nonobstructive voiding pattern. CONCLUSIONS: Urinary retention in female patients with a neobladder can be functional, anatomical or multifactorial. In our series common anatomical findings associated with urinary retention were neocystocele formation and urethral kinking.

Mixed incontinence and cystocele: postoperative urge symptoms are not predicted by preoperative urodynamics.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) frequently presents with urinary incontinence, either urge (UUI), stress (SUI), or mixed (MUI). We sought to determine the effect of high-grade prolapse repair on MUI. METHODS: A retrospective review was performed for 111 patients with anterior POP repair and sling over 4 years. RESULTS: Sixty patients (54%) presented symptomatically with MUI, 25% with SUI, and 9% with UUI, 12% asymptomatic. Occult SUI was found in 21% (UUI plus asymptomatic). Success was seen for SUI in 92% and for POP in 89%. Urge symptoms were present in 63% pre-op and 30% post-op. MUI patients were significantly more likely to experience post-op urgency (p = 0.033). Detrusor overactivity (DO) was seen in 22 MUI patients, but was not predictive of post-op urgency (p = 0.91). CONCLUSIONS: Cystocele patients with MUI are at significant risk for postoperative urge symptoms regardless of DO, and counseling regarding persistent urgency is imperative.

Does levator ani injury affect cystocele type?

OBJECTIVE: To determine the prevalence of levator ani injury in patients with different types of cystocele, as defined by translabial ultrasound, in order to shed light on potential pathophysiological mechanisms. METHODS: The datasets of 222 women who had undergone a physical examination, urodynamic testing and four-dimensional (4D) pelvic floor ultrasound were evaluated offline for prolapse, levator ani hiatal dimensions and levator ani trauma using tomographic ultrasound imaging (TUI), blinded against all clinical and urodynamic data. Cystoceles reaching below the symphysis pubis on ultrasound examination were classified based on bladder neck position, retrovesical angle (RVA) and urethral rotation as Green II (cystourethrocele) or Green III (cystocele with intact RVA). RESULTS: Of 102 women who had a cystocele reaching below the symphysis pubis, 63 were classified as a Green type II cystocele and 39 as a Green type III cystocele. Women with Green type III cystoceles were older (59.4 vs. 48.7 years, P < 0.001), and had more severe prolapse (71 vs. 43%, P = 0.004) and objective voiding dysfunction (39 vs. 18%, P = 0.018). Women with Green III cystoceles also had larger hiatal dimensions and were more often diagnosed with an avulsion of the levator ani muscle (69 vs. 35%, P = 0.001). CONCLUSION: A cystocele with an intact RVA is more likely to be associated with avulsion injury of the levator ani muscle and thus more likely to be caused by birth-related trauma. This contradicts the commonly held belief that such cystoceles are caused by central rather than by lateral fascial defects.

[Impact of sacrospinous vaginal vault suspension on the anterior compartment]. / Impacto de la suspensión de la cúpula vaginal al ligamento sacroespinoso sobre el compartimiento anterior.

OBJECTIVES: A prospective study was conducted to assess the efficacy of sacrospinous vaginal vault fixation and its impact on the anterior compartment. The Pelvic Organ Prolapse Quantification (POP-Q) system was used to quantify pelvic organ prolapse in the apical and anterior vaginal compartments. METHODS: Fifty-eight patients underwent a procedure to correct apical prolapse from March 2003 to February 2006. Mean preoperative and postoperative POP-Q scores were respectively: Aa (+0.74; -1.45); Ba (+3.17; -1.36); C (+3.41; -7.71) (p<0.001). RESULTS: Cure rate was 93.1%. Preoperative and postoperative evaluation of the anterior vaginal compartment was respectively: stage 1 (5.2%; 48.3%), stage 2 (6.9%; 34.5%), stage 3 (74.1%; 5.2%), and stage 4 (13.8%; 0%). De novo cystocele occurred in 87.9% of cases. An improvement was seen in lower urinary tract symptoms of urgency, nocturia, and urge incontinence. CONCLUSIONS: Sacrospinous vaginal vault suspension is effective for the treatment of apical prolapse and leads to formation of cystocele in most cases.

[Cystocele: clinical and therapeutic aspects in the Urology Service of the Gabriel Toure University Hospital Center]. / Cystocele : Aspects Cliniques et Therapeutiques dans le Service D'urologie du CHU Gabriel Toure.

AIMS: Determine the aetiologic factors and evaluate the result of our chirurgical treatment. PATIENTS AND METHODS: It was about a prospective study done from October 1st 2005 to March 31,2007 on all women seen for urinary discomfort in whom cystocele have been found. RESULTS: The hospital frequency of cystocele has been 3.54%. The mean age of our patients has been 48 years. In the patient history dystocic delivery have been found in 7 cases (43.75%), foetal macrosomia in 7 cases, chronic constipation in 1 case (6.25%) and 4 patients were menopausal. For the parity 10 patients were big multi pares, 3 were multi pares (18.75%), 2 were pauci pares (12.5%) and 1 were nullius pare. Cystocele were classed 1st degree in 3 patients, 2nd degree in 9 patients (56.25%) and 3rd degree in 4 others (25%). Anterior plasty of the vaginal wall was done in 11 patients (68.75%) and anterior and posterior plasty of the vaginal wall in 5 patients (31.25%). After 6 months, 62.5% of patients have a good anatomic result and 68.75% a good functional result. Anatomic results were bad in 6.25%. Cystocele is frequent in young women in Mali. It is often related to obstetrical trauma. A rapid diagnosis and care will improve the prognosis.

Constipation: a potential cause of pelvic floor damage?

BACKGROUND: Pelvic floor damage is a major clinical problem usually attributed to obstetric injury. We speculated that constipation may also be an aetiological and preventable factor resulting from repeated stress on the perineum over many years, and this study aimed to test this hypothesis. METHODS: A total of 600 women attending a gynaecological clinic were assessed using a structured questionnaire gathering data on pelvic floor damage, constipation and obstetric trauma. Complete data were available on 596 subjects. KEY RESULTS: The prevalence of pelvic floor damage was 10% (61/596). In this group, constipation was identified in 31% (19/61) of women and obstetric trauma in 31% (19/61). In the group without pelvic floor damage, constipation was present in 16% (86/535) and obstetric trauma in 16% (83/535). In univariate analysis, pelvic floor damage was associated with age (OR: 1.05; 95% CI: 1.03-1.08; P < 0.0001), constipation (OR: 2.36; 95% CI: 1.31-4.26; P < 0.0001) and obstetric trauma (OR: 2.46; 95% CI: 1.37-4.45; P < 0.0028). In multivariate analysis, the OR for age was 1.05 (95% CI: 1.03-1.08; P < 0.0001), for constipation 2.35 (95% CI: 1.27-4.34; P < 0.0001) and for obstetric trauma 1.37 (95% CI: 0.72-2.62; P = 0.3398). CONCLUSIONS & INFERENCES: Constipation appears to be as important as obstetric trauma in the development of pelvic floor damage. Thus, a more proactive approach to recognizing and treating constipation might significantly reduce the prevalence of this distressing problem.