Historical review of the development of urinary continence cause in China

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) share common pathological mechanisms,[1] and both manifest as a tape of pelvic floor dysfunction, often co-occurring and developing concomitantly. Although POP develops concomitantly with evident SUI in some cases, there have been instances wherein POP occurs without prior urine leakage before repositioning the prolapsed organs, but urinary incontinence develops after the prolapsed organs are repositioned. The condition in such cases is termed as occult SUI (OSUI), with an incidence of approximately 23.5% among patients with POP.[2] 1. Epidemiology and pathological mechanisms Despite sharing several epidemiological risk factors such as pregnancy, increased gravidity and parity, obesity, advanced age, persistently elevated intra-abdominal pressures (IAP) (eg, persistent cough or constipation), menopause, and family history, POP and SUI have complex and multifactorial etiologies. Furthermore, advanced age and Green type III cystocele (bladder prolapses to the level of the urinary meatus, the posterior urethrovesical angle <140°, urethral rotation angle ≥45°) are risk factors for concomitant OSUI in patients with POP.[3] Although POP and SUI represent distinct clinical manifestations with a shared cause, which is currently believed to be a class of disorders linked to an imbalance of pelvic floor dynamics, the majority of POP cases involve the anterior vaginal wall or the bladder. This type of prolapse is highly likely to result in laxity and protrusion of the bladder's neck and posterior wall, causing impaired support from the middle posterior urethra. This, in turn, leads to a reduced functional length of the urethra and the development of SUI symptoms.[4] Although current surgical procedures for POP repositioning can correct the anatomical positions of the involved organs, they cannot address problems involving the mechanisms of urinary control, such as sphincter dysfunction, thinning of the urethral mucosa, and autonomic dysfunction of the involved organs. Consequently, SUI becomes particularly prominent in the postoperative period.[5,6] Biomechanical finite element analyses of the pathological mechanisms of pelvic floor stress dysfunction reveal that SUI and POP are disorders of mechanical imbalance inexorably linked to each other. Moreover, they serve as pelvic manifestations of the overall systemic deterioration of the body's mechanical properties. Achieving optimal therapeutic efficacy requires more than just correcting SUI or POP in isolation. It necessitates restoring the overall health of the body and its mechanics through a comprehensive understanding of the body's overall condition and mechanical imbalance post–pelvic floor stress dysfunction.[7,8] 2. Diagnosis and evaluation The diagnosis of POP accompanied by SUI primarily relies on a thorough medical history and specialized examination. Questionnaires and laboratory examinations are not suitable for clear differential diagnosis from POP or SUI alone. 2.1. Medical history The typical symptom of POP accompanied by SUI involves protrusion of a mass from the vagina that can be seen, palpated, or otherwise sensed, which may also be accompanied by urine leakage during activities that increase IAP, such as exercise, laughing, coughing, or sneezing. Some patients may also present with frequent urination, urinary urgency, urge incontinence, or difficult urination. 2.2. Specialist examination Patients should be positioned in lithotomy or, if necessary, a standing position for examination. Observation includes checking for urinary leakage from the external urethral meatus, prolapse of pelvic organs, and maximum extent of organ prolapse at rest, during coughing or breath holding. Results should be recorded using the POP-Q system. Vaginal repositioning testing should be performed to avoid missing a diagnosis of OSUI. Specifically, stress induction testing should be performed after repositioning of the prolapsed organs, preferably in the standing position if possible. In addition, pad weight testing should be performed as a preliminary evaluation of urine leakage. Many methods of repositioning are available, with reliable results achieved by restoring the normal position of the vagina using an appropriately sized pessary or sterile cotton gauze.[9,10] 2.3. Urodynamic testing The 2019 National Institute for Health and Care Excellence guidelines serve as the international consensus to determine whether urodynamic testing is required in cases of POP accompanied by SUI. Urodynamic testing is currently recommended in the following situations: (1) mixed urinary incontinence or urinary incontinence of unknown cause; (2) voiding dysfunction as the primary symptom; (3) SUI with concomitant anterior or apical prolapse; (4) previous history of surgical treatment for urinary incontinence. Notably, this testing should be conducted only after repositioning of the prolapsed pelvic organs, distinguishing it from other urodynamic testing methods. 2.4. Differential diagnosis It is necessary to differentiate among the types of urinary incontinence associated with pelvic organ prolapse, primarily including the following: Urge incontinence: Involuntary urine leakage associated with a strong and sudden need to urinate, rather than leakage triggered by activities such as coughing or sneezing that elevate intra-abdominal pressure. Overflow incontinence: Involuntary leakage of urine due to an overdistended bladder. This is commonly encountered in cases of chronic urinary retention caused by various factors, resulting in continuous or intermittent urine leakage when bladder pressure exceeds urethral resistance. Genuine stress incontinence: A loss of urine due to a rise in intra-abdominal pressure, even when the bladder is not full. Common causes include urethral sphincter damage and congenital or acquired neurogenic diseases. 3. Conservative treatment Conservative treatment is recommended for patients with POP of grade ≤2, as assessed by the POP-Q, accompanied by mild or moderate SUI. The selection of treatment depends on the patient's preferences, disease severity, the benefits and risks of the chosen treatment, and other relevant factors. Various treatment methods are available, including follow-up observation, lifestyle interventions, pelvic floor muscle training (PFMT), pelvic floor physical therapy, pessaries, medication, and traditional Chinese medicine and acupuncture. 3.1. Follow-up observation Follow-up observation is a suitable option for asymptomatic patients, but it should be accompanied by lifestyle intervention guidance and health education. 3.2. Lifestyle interventions All patients diagnosed with POP accompanied by SUI should actively receive behavioral guidance to mitigate factors that exacerbate pelvic floor injury. This may involve weight loss, smoking cessation, avoidance of activities that increase pelvic floor stress, and the treatment of constipation and cough. 3.3. Pelvic floor muscle training Numerous PFMT methods are available, with Kegel exercises being simple yet effective in increasing the strength and coordination of weak pelvic floor muscles. Currently, a recommended duration of 3 continuous months of muscle training is advised for improving pelvic floor dysfunction, especially in cases of mild or moderate SUI.[11,12] 3.4. Physical therapy Biofeedback, adjuvant electrical stimulation, and electromagnetic therapy can enhance the effectiveness of PFMT and shorten the duration of therapy. 3.5. Pessaries Pessaries are devices inserted into the vagina to enhance pelvic floor function by restoring the normal anatomical positions of the uterus, vaginal wall, urethra, and bladder. They represent a first-line conservative treatment option for POP. Specifically, pessaries designed to address urinary incontinence can alleviate the majority of symptoms in patients with mild to moderate POP accompanied by SUI[13] and are particularly suitable for patients with fertility requirements or those for whom surgery is contraindicated. However, proper guidance on usage and regular follow-up visits are essential. 3.6. Medication Generally, medication is not considered a first-line treatment for POP accompanied by SUI. However, local estrogen treatment may be considered if the patient presents with genitourinary syndrome of menopause, which can help alleviate vaginal dryness, reduce urinary tract symptoms, and increase the thickness of the urethral mucosa, indirectly improving symptoms of urinary incontinence.[14] 3.7. Traditional Chinese medicine Electroacupuncture, traditional Chinese medicine, and other procedures can improve pelvic floor support and alleviate symptoms of prolapse and urinary incontinence to some extent, serving as adjuvant treatments. 4. Surgical treatment of POP with SUI Nearly 70% of patients with severe POP exhibit symptoms of SUI.[15] For POP patients with evident SUI, surgical treatments solely addressing POP have limited efficacy for SUI. Hence, we recommend simultaneous surgical treatment of SUI (evidence grade C). Surgical interventions for SUI encompass midurethral slings (MUS) and Burch colposuspension (Burch procedure). 4.1. Midurethral sling Midurethral sling corrects urinary incontinence by strengthening the overactive middle segment of the urethra. With a subjective cure rate of 75%–94% and an objective cure rate of 57%–92% for SUI, MUS stands as a superior treatment for urinary incontinence compared with the Burch procedure, establishing itself as the criterion standard for surgical treatment of female SUI. Medical evidence indicates that, in POP patients with evident SUI preoperatively, simultaneous MUS during pelvic floor reconstruction can reduce the subjective incidence of postoperative SUI and further decrease the need for surgical management of SUI.[16] For SUI patients with characteristics such as small bladder volume, urinary retention, or detrusor muscle dysfunction, preoperative urodynamic testing should be conducted to assess bladder function, and the option of surgical SUI management should be carefully considered. In cases where MUS is performed simultaneously with surgical POP management, it is recommended to tighten the sling and adjust tension after completing pelvic floor reconstruction. Complications of MUS may include bladder and urethral injury, difficult urination, pain in the medial thigh and pelvic cavity, and mesh exposure or erosion. 4.2. Burch procedure The Burch procedure addresses urinary incontinence by elevating the neck of the bladder and restoring the posterior urethrovesical angle. It is currently employed in laparoscopic POP reconstruction when surgical SUI management is necessary. Studies have demonstrated that patients undergoing the Burch procedure exhibit significantly lower overall cure rate and objective cure rate than those undergoing MUS. Thus, the Burch procedure is not considered the first choice for surgical SUI management in patients with POP accompanied by SUI. 5. Surgical treatment of POP with OSUI The choice between a "one-step" and a "two-step" treatment for POP accompanied by OSUI remains a matter of debate. Conducting MUS simultaneously with the surgical management of POP has shown advantages, such as reducing the risk of new-onset SUI postoperation, diminishing the need for postoperative SUI treatment, decreasing the requirements of anesthesia, and lowering medical costs. In addition, it does not affect the patient's ability to void and retain urine, nor does it compromise bladder compliance. However, this approach is associated with an increased incidence of overactive bladder, difficult urination, urine retention, urinary tract infections, and elevated risks of sling erosion and bladder perforation.[17,18] Pelvic organ prolapse patients lacking symptoms of SUI are particularly susceptible to developing OSUI, especially in cases of anterior and central POP. Preoperatively, prolapsed tissues should be repositioned through the vagina before detailed examination to confirm the presence or absence of OSUI to prevent postoperative SUI. We recommend the following methods in the formulation of the surgical plan (Fig. 1): For patients with POP in which SUI was not preoperatively confirmed, vaginal repositioning testing should be performed first. If the result is negative, SUI surgery is not necessary. If the result is positive, the strategy should be formulated considering whether the patient has a previous history of SUI. For patients with a confirmed history of SUI that resolved with increasing prolapse and for those without a history of SUI who do not wish to undergo a second operation, simultaneous SUI surgery can be performed. In summary, patients with POP accompanied by OSUI should be examined on an individual basis to weigh the risks and benefits, the surgical procedure should be carefully selected, and communications with the patient and family members should be timely and thorough.Figure 1: Diagnostic flowchart for POP accompanied by OSUI. POP = pelvic organ prolapse; SUI = stress urinary incontinence. POP = pelvic organ prolapse; SUI = stress urinary incontinence.If simultaneous SUI surgery is deemed necessary, the primary options include both the Burch procedure and MUS, with the choice dependent on the surgical approach for POP (transabdominal or transvaginal). Notably, the efficacy of MUS is better than that of the Burch procedure, and the effectiveness of MUS via the retropubic approach or the transobturator approach is comparable. 6. Prevention and surveillance 6.1. Prevention Pelvic organ prolapse and SUI have the same epidemiological risk factors and therefore similar preventive measures. Improving health during pregnancy and the postpartum period through interventions such as weight control and PFMT exercises combined with breathing exercises.[19] Avoiding activities that increase IAP, such as managing constipation and minimizing intense physical activity. Controlling body weight, avoiding/quitting smoking, and maintaining nutritional balance. Postmenopausal patients can undergo appropriate hormone replacement therapy after evaluation by a physician, thus improving overall health and managing symptoms of genitourinary syndrome of menopause. 6.2. Surveillance Surveillance of patients with POP accompanied by SUI should include the following: Follow-up for conservative treatment: At 3–6 months of treatment, follow-up should include a 72-hour voiding diary, a 1-hour urine pad test, pelvic floor muscle myoelectric testing, the International Consultation on Incontinence Questionnaire—Urinary Incontinence Short Form (ICI-Q-SF), and urodynamic testing if necessary.[20] Follow-up for surgical treatment: At 6 months postoperatively, the patient should be examined for short-term complications such as infection, bleeding, and tissue injury. After 6 months, the patient should be examined for long-term complications and efficacy of surgical treatment. Follow-up examination should include a 72-hour voiding diary, a 1-hour urine pad test, the ICI-Q-SF, Pelvic Floor Distress Inventory-20, Pelvic Organ Prolapse Distress Inventory-6, Urinary Distress Inventory-6 Colorectal-Anal Distress Inventory-8, Pelvic Floor Impact Questionnaire-7, the American Urological Association Symptom Score, and other questionnaires, as well as urodynamic testing, B-scan ultrasound of the pelvic floor, cystography, and other examinations as necessary to evaluate bladder function and mechanical recovery of the pelvic floor. Patients with mesh exposure should be referred to a trained and experienced pelvic floor specialist for further diagnosis and treatment.[21] The use of standardized CTS terminology and standardized documentation for complications is recommended to facilitate future management and referral. This article is a second publication and English translation of Chinese expert consensus on the diagnosis and treatment of pelvic organ prolapse and stress urinary incontinence, which was first published in Zhonghua Miniao Waike Zazhi, 2023, 44(6):401–404. doi: 10.3760/cma.j.cn12330-20230516-00172

Objective To introduce a urodynamic classification of female patients with symptoms of overactive bladder(OAB) and discuss its clinical significance. Methods From January 2015 to January 2017, 62 female patients from Peking University People's Hospital who diagnosed clinically with OAB and underwent preoperative urodynamic test were involved in this study. Female OAB patients can be stratified into four groups based on the chief complaints and the urodynamic test, including typeⅠ-no evidence of detrusor overactivity(DO) on urodynamic test, patients can feel urgency and have no urinary incontinence, typeⅡ-involuntary detrusor contraction present, patients aware and able to abort them and have no urinary incontinence, type Ⅲ-involuntary detrusor contraction present, patients aware and able to contract the sphincter but can not abort contractions and have urinary incontinence and type Ⅳ-contractions present, and patients unaware and unable to contract the sphincter or abort contractions and have urinary incontinence.According to the classification, the amount of the four types of OAB patients were 8, 22, 25 and 7, respectively.The data of height, age, weight showed no statistical significance (P>0.05) .The amount of the concomitant diseases of the type Ⅰ, Ⅱ and Ⅲ showed no obviously difference(P>0.05), but the type Ⅳ was higher than the other three types(P 0.05)and AUASS scores(16.38±5.26 vs. 16.59±5.11, P>0.05)of the typeⅠandⅡhave shown no obviously difference. The preoperative OABSS(9.00±2.35 vs.9.71±3.04, P>0.05)and AUASS(20.59±3.95 vs. 22.00±4.97, P>0.05)scores of the type Ⅲ and Ⅳ have shown no obviously difference.The preoperative scores of the OABSS scores and AUASS scores of the type Ⅲ and the type Ⅳ were obviously higher than that of the typeⅠand the typeⅡ(P<0.05 ). In this study, 16 of the 62 patients were treated with tolterodine, 46 patients were treated with solifenacin, with the average duration of drug therapy of 3.4 months (0.5-20.0 months). The postoperative scores of the OABSS and AUASS were followed up. The treatment outcomes among different OAB types were compared. Results The 62 patients were followed up from 6 to 20 months, with an average of 11.2 months.The improvement of the OABSS scores of the typeⅠandⅡ(3.63±0.74 vs.3.86±0.89, P>0.05) have shown no obviously difference. The improvement of the OABSS scores of the type Ⅲ( 6.40±1.17)were obviously higher than the typeⅠ, Ⅱ and Ⅳ( 1.71±1.38)(P 0.05)have shown no obviously difference. The improvement of the AUASS scores of the type Ⅲ(15.28±4.32)were obviously higher than the typeⅠ, Ⅱ and Ⅳ(8.14±4.34)(P<0.05). The improvement of the AUASS scores of the type IV were obviously inferior to the typeⅠ, Ⅱ and Ⅲ(P<0.05). Conclusions The type Ⅳ OAB presented with the worst outcome and the type Ⅲ OAB presented with the best among the four types of OAB.The classification system will have a suggestive significance to predict the prognosis and the therapeutic effect of the patients with OAB. Key words: Overactive bladder; Woman; Clissification; Urodynamic test

Questionnaires to Assess Urinary and Anal Incontinence: Review and Recommendations

Pelvic floor muscle strength and the incidence of pelvic floor disorders after vaginal and cesarean delivery

Background: The aim of this pan-Slovene crossover survey was to assess how often the family practice physicians are dealing with urinary incontinence (UI) and overactive bladder (OAB) at their offices and to assess how are their patients with these disorders managed. Methods: In this questionnaire-based study we randomly selected 100 family practice physicians and their 50 patients, aged between 40–70 years, who had come consecutively to their offices. They all filled out questionnaires in a way that enabled their privacy and anonymity. Data from questionnaires was managed by statistical software program SPSS. Results: 68 % of physicians and 3057 of their patients (88.9 %) agreed to participate in the study. In case of UI or OAB, physicians most commonly refer patients to other specialists, rule out uroinfection, explain them the pelvic floor muscle training (PFMT) and prescribe pads. The UI prevalence in patients was 30.6 %, and was more common in women than in men (39.3 % vs. 14.1 %, respectively, p &#x60 0.001). Most patients were diagnosed with mixed UI (69.6 %), followed by stress UI (16.8 %) and urgency UI (13.6 %). OAB (urgency) was found in 35.2 % of patients and was more common in women than in men (40.6 % vs. 24.8 %, respectively, p &#x60 0.001). Only 51.4 % of women and 24.8 % of men exactly knew what PFMT meant, however, the knowledge of bladder training was even worse (17.9 % of women and7.7 % of men). Conclusions: Both, UI and OAB represent a significant problem among patients attending the family practice physician office. It seems that the knowledge of both dysfunctions is satisfactory among physicians. The majority of patients would tell their doctors about UI and OAB and would also receive appropriate instructions regarding the bladder training and PFMT, both methods being very important for the prevention and treatment of these dysfunctions.

Objective: Biofeedback pelvic floor muscle training (PFMT) has been widely used in treatment of stress urinary incontinence, idiopathic detrusor overactivity, learned dysfunctional voiding and chronic pelvic pain. Only limited data have been reported on this treatment of overactive bladder (OAB) and voiding dysfunction in adults. This study used PFMT to treat a group of patients with symptoms of OAB or voiding dysfunction due to poor relaxation of the urethral sphincter or pelvic floor muscles. Materials and Methods: All patients were treated with a standard 12-week step by step program which included instruction in voiding physiology, identification of the pelvic floor muscles, correct contraction of the pelvic floor muscles, increase in endurance of the pelvic floor muscles, and a continuing program at home. The symptomatic improvement and uroflowmetry parameters were compared between baseline and post-PFMT. Results: A total of 124 patients entered this study, but only 68 (55%) completed the program. Among these patients, 52 (76.3%) had symptomatic improvement. After PFMT, the maximum flow rate and voided volume all increased in both genders and in patients with OAB as well as those with voiding dysfunction. Conclusions: The results of this study demonstrated that with a proper training program, 76.5% of patients with OAB and voiding dysfunction can achieve improvement in symptoms using biofeedback PFMT. The severity of frequency urgency symptoms can be reduced and voided volume and Qmax can be increased.

Objective To observe the clinical effect of pelvic floor rehabilitation training on patients with pelvic floor dysfunction after delivery through vagina. Methods From January 2017 to December 2017, 96 patients with pelvic floor dysfunction treated in the Maternal and Child Health Hospital of Lishui were randomly selected for clinical study.The patients were divided into observation group and control group by random number method, with 48 cases in each group.The control group was given pelvic floor dysfunction knowledge education, psychological counseling and general treatment methods such as guiding patients to perform functional exercises.The observation group received pelvic floor rehabilitation training on the basis of the treatment plan of the control group.The symptoms related to pelvic floor dysfunction, pelvic floor contraction ability before and after treatment, pelvic floor function and sexual quality of life were compared between the two groups. Results The incidence rates of clinical symptoms such as organ prolapse, urinary incontinence, asexuality and sexual intercourse pain in the observation group were 8.33%, 6.25%, 8.33% and 10.42%, respectively, which were significantly lower than those in the control group (25.00%, 27.08%, 22.92% and 27.08%) (χ2=4.800, P=0.028; χ2=7.500, P=0.006; χ2=3.872, P=0.049; χ2=4.376, P=0.036). There was no statistically significant difference between the two groups in grade I-V before treatment(P>0.05). After treatment, there were 2 cases, 4 cases, 8 cases, 18 cases and 17 cases in the observation group with grade I-V, which were significantly better than those in the control group (8 cases, 7 cases, 10 cases, 16 cases and 7 cases), and there was statistically significant difference (χ2=8.102, P=0.044). After treatment, the pelvic floor muscle tension of the observation group was higher than that of the control group[(4.16±0.33)grades vs.(3.84±0.27)grades], the difference was statistically significant(t=5.200, P=0.000). The sexual life quality score of the observation group was (87.33±10.24)points, which was significantly higher than (78.62±8.29)points in the control group(t=4.580, P=0.000). The total effective rate of the observation group was 95.83%, which was significantly higher than that of the control group (83.33%, χ2=4.019, P=0.048). Conclusion Pelvic floor rehabilitation training has good clinical effect on pelvic floor dysfunction after vaginal delivery.It can significantly improve pelvic floor function and sexual life ability, improve pelvic floor muscle tension and reduce visceral prolapse.It has important clinical application value. Key words: Pelvic floor; Hospitals, convalescent; Natural childbirth; Postpartum period

To observe the multiple symptom distribution, severity and quality of life of female pelvic floor dysfunction(FPFD) patients with constipation as chief complaint. One hundred FPFD patients with constipation as chief complaint from Speciaty Outpatient Clinic, Pelvic Floor Center of Nanjing Municipal Hospital of Traditional Chinese Medicine between September 2015 and February 2017 were retrospectively enrolled in this study. A comprehensive medical history questionnaire survey and systematical evaluation of severity and quality of life of these patients with constipation was conducted. Constipation scoring system scale (CSS) and patient-assessment of constipation quality of life questionnaire (PAC-QOL) were applied to evaluate the constipation. Other scales included: (1)pain visual analogue scale (VAS) and short form-36 questionnaire (SF-36): if combined with chronic functional anal rectal pain; (2) international consultation on incontinence questionnaire-short form (ICIQ-SF) and urinary incontinence quality of life questionnaires (I-QOL):if combined with urinary incontinence; (3) fecal incontinence severity score scale (Wexner-FIS) and fecal incontinence quality of life questionnaire (FI-QOL):if combined with fecal incontinence. The mean age of 100 FPFD patients was (57.9±13.9) (24-89) years and the mean disease course was (7.0±8.2)(0.5-40.0) years. Seventy-five cases (75%) were complicated with anal pain, 70 with urinary incontinence, 37 with rectocele, 19 with nocturia, 11 with urinary frequency, 10 with defecation incontinence. Complication with only one symptom was observed in 20 cases (20%), and with two or more symptoms was observed in 80 cases (80%). Pelvic floor relaxation syndrome patients were dominant (58 cases, 58%). The severity of constipation (CSS) was 6-22 (13.89±3.79) points and the quality of life (PAC-QOL) was 45-133 (87.13±18.57) points in FPFD patients. VAS and SF-36 of patients combined with chronic functional anal rectal pain were 1-8 (3.0±1.9) points and 14.4-137.0(71.5±31.4) points respectively. ICIQ-SF and I-QOL of patients combined with urinary incontinence were 1-17 (6.1±3.6) points and 52-110 (90.0±15.8) points respectively. Wexner-FIS and FI-QOL of patients combined with fecal incontinence were 1-11 (4.4±3.0) points and 52-116 (83.4±23.3) points respectively. The symptoms of FPFD patients with constipation as chief complaint are complex. They are mainly complicated with anal diseases, then urinary incontinence, and mostly with more than 2 symptoms. Their quality of life is poor.

Female pelvic organ dysfunction occurring in eastern and central Africa results in significant morbidity and adverse social and mental health sequelae.Lack of adequate resources available for health care compounds the suffering faced by these women. Obstetric fistula (OF), chronic 4th degree obstetric tears and severe pelvic organ prolapse(POP) are all common gynaecological morbidities seen in Uganda, D.R. Congo and Ethiopia. Despite successful closure of OF, bladder dysfunction and incontinece may persist due to detrusor overactivity, stress urinary incontinence and voiding dysfunction. Chronic 4th degree obstetric tears require effective surgical repair. Women suffering with severe POP need to be given surgical and non‐surgical options of treatment. Non‐surgical options include the availability and use of support pessaries. This research has focused on evaluation of post‐OF bladder dysfunction assessment and treatment options. In particular, urodynamic bladder function studies were utilized and a bulking agent used as an option for post-‐OF repair continence surgery. A surgical repair technique for chronic 4th degree obstetric tears has been described with post‐operative follow‐up of women giving encouraging results. Support pessaries have been introduced and evaluated for women experiencing severe POP. In order to be able to improve treatment and management options available for women affected with such pelvic floor dysfunction, additional information and understanding regarding risk factors and anatomical defects are needed. The relevance of height and age as risk factors for OF have been evaluated here. Pelvic floor anatomy as measured with 4D pelvic floor ultrasound includes levator hiatal dimensions and identification of levator muscle trauma. Assessment of nulliparous Ugandan women has documented differences in levator hiatal dimensions compared to non‐Ugandan women, and Ugandan women with OF,chronic 4th degree obstetric tears and severe POP have also been scanned and levator hiatal areas and incidence of levator muscle trauma compared. Significantly, the levator hiatal area in women with OF is smaller than in women with chronic 4th degree obstetric tears and severe POP. Possible reasons for these findings are discussed. The incidence of levator muscle 3 defects in women with pelvic floor dysfunction is compared with all 3 groups experiencing a similar high rate of complete levator muscle trauma. The social and mental health of women with pelvic floor dysfunction including risk of domestic violence has been assessed. High levels of loss of social cohesion and mental health dysfunction have been identified in women with OF, chronic 4th degree obstetric tears and severe POP. The social and mental health of women with pelvic floor dysfunction including risk of domestic violence has been assessed. High levels of loss of social cohesion and mental health dysfunction have been identified in women with OF, chronic 4th degree obstetric tears and severe POP. Through identifying and highlighting the health sequelae faced by women with pelvic floor dysfunction including OF, chronic 4th degree obstetric tears and severe POP, effective treatment and management options can be evaluated and promoted. Further research is required to consolidate the peri­operative outcomes of the surgical techniques described here with functional long­term outcomes necessary to guide future recommendations. Understanding risk factors associated with the development of pelvic floor dysfunction may guide strategies for prevention. Social and mental health dysfunction needs to be identified and addressed within this group of women with the availability of adequate support networks and treatment. In addition, there must be community­wide awareness of the prevalence of domestic violence with effective solutions promoted.

The pelvic floor is a tunnel or dome-shaped muscular sheath made up of striated muscle and is positioned to enclose and support the genitourinary and anorectal compartments. The pelvic floor forms the inferior boundary of the abdominopelvic cavity extending from the pubic symphysis anteriorly to the coccyx posteriorly and between the two pelvic side walls. There are four layers: the endopelvic fascia, the muscular diaphragm or levator plate, the perineal membrane or urogenital diaphragm, and the superficial transversus perinei. The pelvic floor has a dynamic mechanization of complex voluntary and involuntary muscles, supporting ligaments, fascial encasings, and complex neural wiring. Pelvic floor dynamics is crucial in maintaining continence and evacuation of the bladder/bowel, supporting the pelvic organs, maintaining the dynamics of the birth canal, and optimized sexual function. The functional dynamics of the pelvic floor results in myriad clinical presentations. It is necessary to understand the possible symptom complexes in relation to different compartments of the pelvic floor. The three compartments, i.e., anterior, middle, and posterior, relate to symptomatology arising from the urinary, genital, and defecatory system complexes, respectively. These three compartments act like “the spokes of a wheel,” i.e., the pelvic floor (Agarwal et al. 2012). The colorectal surgeon deals mostly with the defecatory aspect of the pelvic floor. Constipation is an index symptom of anorectal dysfunction which in itself is an index parameter of pelvic floor dysfunction (Agarwal et al. 2013). Pelvic floor dysfunction refers to a wide range of disorders which occur due to weakness or tightness of muscles of the pelvic floor. Apart from constipation, pelvic floor dysfunctions include fecal incontinence, urinary incontinence, overactive bladder, pelvic discomfort/pain syndromes, sexual dysfunction, and pelvic organ prolapse (rectocele, cystocele, urethrocele, and rectal prolapse). The most common and definable conditions include fecal incontinence, urinary incontinence, and pelvic organ prolapse. The interdependence and interplay of all these symptoms are clinically relevant as they are just like different spokes in the wheel of pelvic floor dysfunction (Aschkenazi and Goldberg 2009; Keller and Lin 2012).

Objective To evaluate the diagnostic and therapeutic status of lower urinary tract symptoms (LUTS) of benign prostatic hyperplasia (BPH) in urological outpatients. Methods The survey was conducted at 57 urological clinics in 14 cities during the period of October-December 2011. All surveyed male outpatients were inquired about whether there was a history of LUTS/BPH or not. Then eligible patients received a more detailed questionnaire for LUTS. Results Among a total of 6 200 male outpatients, 47.4%(n=2 940) had a history of LUTS/BPH. The rate for LUTS was 30.0% (n=882) in patients aged under 40 years and 60.0%(n=1 764) in those aged over 60 years. The major complains included frequency (72.0%), urgency (53.0%) and nocturia (48.0%). At a rate of 63.0%, the patients aged 71-80 years came more to a hospital for nocturia than 61-70 years (52.0%) and 51-60 years (49.0%). The average International Prostate Symptom Score (IPSS) was 14.98(6-35) and 59.0% patients had moderate symptoms and 26.0% severe symptoms. The average score of quality-of-life was 4.12(1-6) points. And the average overactive bladder symptom score (OABSS) was 5.78(3-15) points and 56.0% patients had moderate overactive bladder (OAB) and 3.0% severe OAB. Urinalysis was largely normal. The main causes for LUTS included OAB (25.2%), BPH and OAB (20.4%), BPH (20.2%), prostatis (20.2%) and urinary infection (11.8%). Conclusions LUTS and BPH are common in urological outpatients. And the incidence is rising yearly. Clinical examinations and drug regimens should be timely adjusted according to the etiology. And patient education should be strengthened at the same time. Key words: Prostatic hyperplasia; Lower urinary tract symptoms; Survey

Objective To investigate the relationship between preoperative urodynamic parameters and the improvement of overactive bladder(OAB)symptoms after GreenLight laser vaporization, and to explore prognostic factors for improvement of OAB symptoms in the elderly. Methods A retrospective study was conducted in 100 benign prostatic hyperplasia(BPH)patients undergoing GreenLight laser vaporization at the Department of Urology of Beijing Hospital from July 2015 to March 2017.All patients completed a preoperative urodynamic examination and received GreenLight laser vaporization.Clinical data including age, prostate-specific antigen(PSA), prostate volume, international prognostic scoring system(IPSS), overactive bladder symptom score(OABSS), quality of life(QOL)and urodynamic parameters were collected.The related factors for improvement of OAB symptoms after GreenLight laser vaporization were analyzed by a binary Logistic regression analysis. Results All patients underwent surgery successfully and completed a 12-month follow-up.Both urinary storage and voiding symptoms improved at 3 and 12 months after GreenLight laser vaporization(P<0.05). The scores of IPSS, IPSS storage(IPSS-S), IPSS voiding(IPSS-V), OABSS and QOL and nighttime voiding frequency decreased and urinary storage and voiding symptoms improved at 3 and 12 months after GreenLight laser vaporization, compared with pre-surgery data(P<0.05). The success rates of storage symptom improvement at 3 and 12 months after GreenLight laser vaporization were 62.0%(62/100)and 68.0%(68/100)evaluated by IPSS-S and 68.0%(68/100)and 75.0%(75/100)by OABSS, respectively.Multiple Logistic regression analysis showed that age, detrusor contractility, residual urine volume and nighttime voiding frequency were independent influencing factors for prognosis(OR=35.714, 0.352, 0.110 and 0.040, P=0.000, 0.027, 0.018 and 0.002). Conclusions GreenLight laser vaporization is an effective method in treating BPH with OAB.Age is an independent unfavorable factor and the residual urine volume, nighttime voiding frequency and detrusor contraction are independent influencing factors for prognosis.Enough attention should be paid to these related parameters before surgery. Key words: Prostatic hyperplasia; Urinary bladder, overactive

Objective To investigate the effect of biofeedback electrical stimulation on the recovery of functional indexes after pelvic floor reconstruction. Methods A retrospective study was performed on 66 cases of patients with pelvic floor dysfunction who were admitted from March 2014 to October 2016.Patients were randomly divided into the observation group and normal group, with 33 cases in each group.Both groups of patients underwent pelvic floor reconstruction.Three months after operation, patients in the normal group were treated with pelvic floor muscle training, the others in the observation group were treated with pelvic floor muscle exercise combined biofeedback stimulation.Before and 6 months after operation, the pelvic organ detachment index(POP-Q), pelvic floor muscle tension test grade, urinary incontinence index and female sexual function(FSFI)score of the two groups were compared. Results The results of rank and test showed that there were no significant differences between the two groups before and after treatment in POP-Q index, pelvic floor muscle tension grade, urinary incontinence index, FSFI scores, and the difference was not statistically significant(P>0.05). Six months after operation, the POP-Q index, pelvic floor muscle tension grade and urinary incontinence of the observation group were all higher than those of the normal group(P<0.05); the FSFI score of the observation group was higher than that of the normal group(P<0.05). Conclusion Biofeedback stimulation can improve the treatment effect of pelvic floor reconstruction in PFD patients, which can promote the recovery of muscle strength in the basin, relieve the symptoms of PFD, and improve the sexual function of patients. Key words: Biofeedback electrical stimulation; Pelvic floor dysfunction; Pelvic floor reconstruction; Catheter retention time; Pelvic floor muscle strength recovery

Objective To explore the clinical effect of pelvic floor muscle rehabilitation therapy to recover pelvic floor dysfunction.Methods 435 cases of 6-8 weeks postpartum urinary incontinence patients were chosen.The urinary incontinence questionnaire （ ICI-QSF） ,and Female Sexual Function Index questionnaire （ FSFI questionnaire） were used to detect maternal urinary incontinence （UI） investigation,pelvic organ prolapse （POP-Q） degree and quality of sexual life questionnaire.Ⅰ muscle,Ⅱ muscle strength and fatigue, vaginal and the change of dynamic pressure for pelvic floor functional change before and after Pelvic floor rehabilitation were compared.Pelvic floor mus-cle rehabilitation treatment included：imitation bioelectricity stimulus,biofeedback,scene reflection training and Kegel exercises.Results After pelvic floor muscle rehabilitation,pelvic floor function improved significantly,pelvic floor muscle strength increase, decrease fatigue, vaginal dynamic pressure rose significant difference：Electrical values （μV） before treatment （5.6 ±1.8）,after treatment（15.1 ±4.6）,t =3.6,P 〈0.05;Vaginal dynamic pressure （cmH2O） before treatment（48.7 ±11.0）,after treatment （86.3 ±5.1）cmH2O（t=7.2,P〈0.01）;Fatigue obvi-ously improved,（P〈0.01）,the effect of Urinary incontinence treatment is very obvious （t=5.6,P〈0.05）and pelvic organ prolapse improved significantly：Before treatment vaginal wall prolapse II degrees 63 people,after treat-ment 14 people,remission rate 82%,and Before treatment uterine prolapse 172 people,after treatment uterine pro-lapse 39 people,the response rate of 77.3% （P 〈0.01）,sexual function improved significantly：before treatment score is （78.00 ±20.45） and after treatment scores is （100.00 ±25.36）,t=8.6 （P〈0.01）.Conclusion Pelvic floor muscle rehabilitation effectively improve postpartum women pelvic floor function,can achieve the purpose of the treatment of urinary incontinence,improve pelvic organ prolapse and the quality of sex life. Key words: Urinary incontinence ; Pelvic floor disorders ; Postpartum period; Rehabilitation; Neurofeedback

Objetivos: estimar a prevalência de incontinência urinária e de seus subtipos (incontinência urinária de esforço, bexiga hiperativa e incontinência mista), a prevalência do sintoma de noctúria, e avaliar o impacto dessas condições sobre a qualidade de vida na população de idosas atendida para vacinação numa Unidade Básica de Saúde de Niterói-RJ. Métodos: estudo observacional descritivo, com utilização das versões brasileiras do International Consultation on Incontinence Questionnaire - Short Form e do King's Health Questionnaire, respectivamente, para triagem de mulheres com incontinência urinária e para avaliar o impacto da incontinência urinária e da noctúria sobre a qualidade de vida. Participaram do estudo 66 mulheres. Resultados: a média das idades foi de 69,6±7,2 anos. Com o International Consultation on Incontinence Questionnaire - Short Form, a prevalência de incontinência urinária foi de 42,4%, sendo que 42,9% das idosas incontinentes referiram que a perda interferia nas suas atividades diárias. A prevalência de incontinência urinária de esforço, bexiga hiperativa e incontinência mista foi de 15,2%, 12,1% e 10,6%, respectivamente. Dentre as mulheres incontinentes, 20 aceitaram responder ao King's Health Questionnaire, tinham incontinência mista 11 delas (55%) e 16 apresentavam noctúria (80%). Houve comprometimento da qualidade de vida em todos os domínios. Conclusão: a prevalência de incontinência urinária foi elevada na população estudada. Com a utilização do questionário de triagem, a incontinência urinária de esforço foi o subtipo mais comum, ao passo que a utilização do questionário de avaliação de qualidade de vida mostrou prevalência mais elevada de incontinência mista. A frequência de noctúria foi estimada somente para as mulheres que responderam ao King's Health Questionnaire. Houve comprometimento da qualidade de vida em todos os domínios avaliados.