Retrospective analysis clinical characteristics of female stress urinary incontinence and efficacy of transobturator tension-free vaginal tape procedure

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

Surgical Treatment of Female Stress Urinary Incontinence: AUA/SUFU Guideline

To evaluate the clinical outcome of anti-incontinence sling in the treatment of occult stress urinary incontinence (OSUI) during reductive surgery for advanced pelvic organ prolapse (POP). From Jun. 2003 to Dec. 2012, 78 patients with OSUI underwent reductive surgery for advanced POP such as high uterosacral ligament suspension, sacrospinous ligament suspension and sacral colpopexy in the First Affiliated Hospital, General Hospital of People's Liberation Army. Among them, 41 patients received reductive surgery alone was enrolled in non-concomitant anti-incontinence group and the other 37 patients who underwent same surgery with tension-free vaginal tape (TVT) or tension-free vaginal tape-obturator technique (TVT-O) was in anti-incontinence group. The patient's demography, objective and subjective outcomes, as well as complications and injures were compared between the two groups. The pelvic organ prolapse quantitation (POP-Q) was used to evaluate the objective outcomes of POP. Urinary distress inventory (UDI-6) and incontinence impact questionnaire short form (IIQ-7) were used to evaluate the subjective outcomes of stress urinary incontinence (SUI). Compared with the non-concomitant anti-incontinence group, the objective outcomes of reductive surgery exhibited no significant differences (100%, 78/78), and only the operation time of anti-incontinence group slightly increased 16 minutes. The occurrence rate of postoperative SUI was 12% (5/41), 15% (6/41), 17% (7/41) respectively after the operation at 2-month, 6-month and 12-month follow up in the non-concomitant anti-incontinence group; and the occurrence rate of the anti-incontinence group was 3% (1/37), 3% (1/37), 3% (1/37); but none of patients in the two groups require further surgery for stress urinary incontinence. Mean score of UDI-6 and IIQ-7 in all the patients decreased significantly after operation at 2-month, 6-month and 12-month follow up (all P < 0.01). However, there was no statistic difference between the two groups (P > 0.05). It is still difficult to make decision for concomitant anti-incontinence procedure in those patients with OSUI, who are undergoing reductive surgery because of advanced POP. Whether the patients will benefit more from anti-incontinence sling depends largely on strict preoperative evaluation for the severity of SUI. The patients with severe SUI are supposed to benefit most from anti-incontinence sling. However, a two-step approach to correct the postoperative stress urinary incontinence is also reasonable.

Objective To systematically review the efficacy and safety of prolapse surgery versus combined prolapse and midurethral sling surgery in women with pelvic organ prolapse and stress urinary incontinence. Methods Databases including PubMed, EMbase, the Cochrane Library(Issue 7, 2016), Web of Knowledge, CNKI, CBM, WanFang Data and VIP were searched from inception to July 31th 2016, to collect randomized controlled trial(RCT) of combined prolapse and midurethral sling surgery versus prolapse surgery for pelvic organ prolapse and stress urinary incontinence.Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies.Then, meta-analysis was performed using RevMan 5.3 software. Results A total of 4 RCT involving 446 patients were included.The results of meta-analysis showed that, for postoperative outcomes, compared with prolapse surgery, the incidence of urinary incontinence, stress urinary incontinence, urgency urinary incontinence, any treatment for SUI, surgery for stress urinary incontinence[RR=0.57, 95%CI(0.46~0.70), P<0.000; RR=0.24, 95%CI(0.10~0.60), P=0.002; RR=0.58, 95%CI(0.39~0.85, P=0.006; RR=0.20, 95%CI(0.06~0.67), P=0.009; RR=0.07, 95%CI(0.01~0.56), P=0.010]were lower in combined prolapse and midurethral sling surgery.For complications, the incidence of bladder perforation or injury, urinary tract infection, incomplete bladder emptying at 1 week[RR=9.72, 95%CI(1.78~53.01), P=0.009; RR=1.77, 95%CI(1.23~2.54), P=0.002; RR=1.39, 95%CI(1.06~1.81), P=0.020]were higher in combined prolapse and midurethral sling surgery, while there were no statistical differences between the two groups in the incidence of voiding dysfunction, vaginal tape erosion, major bleeding or vascular complication. Conclusion For women with pelvic organ prolapse and stress urinary incontinence, compared to prolapse surgery, the incidence of urinary incontinence and treatment of urinary incontinence is lower in combined prolapse and midurethral sling surgery, the incidence of partial complications is higher in combined prolapse and midurethral sling surgery.Due to the limited quality and quantity of the included studies, more high quality studies are needed to verify the above conclusion. Key words: Urinary incontinence, stress; Pelvic organ prolapse; Meta-analysis

Objective To investigate the application value of MRI in evaluating the disorders of pelvic floor in female stress urinary incontinence (SUI). Methods From January 2017 to January 2019, the patients in the SUI group and the control group of Beijing Chaoyang Hospital, Capital Medical University were prospectively collected. Some patients in the SUI group were treated with tension-free vaginal tape (TVT). The dynamic MR was performed in both SUI patients and volunteers, and the following functional MR parameters were assessed between two groups: the urethral length and urethral hypermobility; the opening of urethral and bladder neck; and the pelvic organ prolapse. For SUI patients, the functional changes of the pelvic floor on MRI after TVT was also analyzed. Chi-square test, rank-sum test and t test were used. Results Comparing with the control groups (n=25), the urethral hypermobility, shortening functional urethral length, bladder neck funneling and urethra opening were significantly associated with SUI group (n=33). Thirty one patients were treated with TVT, 12 of them were reexamined with MRI at 3 to 6 months after operation. Postoperative MR showed that SUI patients had lower risk of the urethral opening and bladder neck funneling (P 0.05). Conclusion MRI can accurately evaluate pelvic floor function of SUI patients. However, TVT did not significantly improve weak pelvic supporting structures and pelvic organ prolapse. Key words: Urinary incontinence, stress; Magnetic resonance imaging; Tension-free vaginal tape; Pelvic floor disfunction; Pelvic floor

To evaluate the safety and efficacy of modified Prolift pelvic floor reconstruction with improving the placement of Prolift-A in treatment of severe pelvic floor dysfunction and stress urinary incontinence (SUI). From July 2008 to September 2010, 170 cases with severe pelvic organ prolapse (POP) treated by modified Prolift pelvic floor reconstruction surgery in Fuzhou General Hospital were enrolled in this study. The Prolift-A was laid tension-free under the mid-urethra with the position of Prolift-A displaced from the neck of bladder to the mid-urethra. No concomitant tension-free urethra suspender via vagina was performed. Primary outcomes were assessed with POP quantitation (POP-Q) system to evaluate the postoperative anatomical replacement stage. Secondary outcome measure were: urogenital distress inventory 6 (UDI-6), the incontinence impact questionnaire 7 (IIQ-7) and the pelvic floor incontinence questionnaire 7 (PFIQ-7) to evaluate the impact on life quality at the follow-up of 1, 6, 12 months. At 6 and 12 months after surgery, 168 cases and 163 cases were followed up. The anatomical cure rates were 98.8% (166/168) at 6 months and 97.5% (159/163) at 12 months, respectively. One case with bladder injury and 1 case with rectum injury were observed. Five cases with recurrence were observed, including 2 cases with anterior vagina prolapse, 2 cases with uterine prolapse and 1 case with posterior vagina prolapse. Meanwhile, 3 cases with hematoma and 7 cases with mesh erosion were observed. Quality of life of all patients were improved significantly by UDI-6, IIQ-7 and PFIQ-7 scoring system evaluation. Among 79 POP patients with SUI, the cure rate of SUI was 93.7% (74/79). Of 5 cases with symptomatic SUI, 2 cases were needed surgical intervention. Twenty-three cases were found with minimal SUI symptoms and subjective satisfaction without objective influence on quality of life. Seven patients presented dysuria after surgery, 5 cases recovered urination with 10 days, 1 case recovered with 1 months, and 1 case with 6 months by bladder drainage. Eleven cases with discomfort urination and 3 cases with slow urination were found. The modified Prolift pelvic reconstructive surgery was safe and efficacy intervention in treatment of POP and prevention of SUI.

“Inside-out” Transobturator Tension-free Vaginal Tape for Management of Occult Stress Urinary Incontinence in Women Undergoing Pelvic Organ Prolapse Repair

Objective To investigate effects of a modified tension-free vaginal tape-obturator(TVT-O)on treating female stress urinary incontinence(SUI)with slight anterior vaginal prolapse. Methods 28 females with stress urinary incontinence accepted a modified tension-free vaginal tape- obturator surgery by suspending mid-urethra, including 13 cases with anterior vaginal prolapse(11 cases were slight,2 cases were midrange), and 15 cases with pure stress urinary incontinence. Results All patients showed no stress urinary incontinence symptoms completely after the modified tension-free vaginal tape-obturator surgery, with average operation time of 20 minutes, and average intraoperative hemorrhage volume was 40 mL. A 6-month follow-up of 27 patients revealed no recurrence, and previous slight anterior vaginal prolapse in 10 patients become less prominent, while in 2 patients improved significantly. Conclusion The modified tension-free vaginal tape-obturator surgery is effective, minimally invasive, less complicated, and suitable for female stress urinary incontinence with slight anterior vaginal prolapse patients. Key words: stress urinary incontinence; anterior vaginal prolapse; tension-free vaginal tape- obturator; mesh; female

Objective To explore the relationship of vaginal wall estrogen receptor expression with stress urinary incontinence and pelvic organ prolapse. Methods From October 2009 to October 2011 in our hospital, we used IHCA to detect positive rate of vaginal wall estrogen receptors of patients with stress urinary incontinence（Group A）, patients with pelvic organ prolapse（Group B） and Group A ＋ B before and after menopause, and selected the same period patients received gynecological examination with benign diseases（control group）. Results Compared with control group, expression of ER-positive of 3 groups significantly decreased before and after menopause（P 〈 0.05）, while the positive expression rate of multiple comparison among 3 groups had no significant difference（P 〉 0.05）. Conclusions Vaginal wall estrogen receptor levels both significantly decrease in patients with stress urinary incontinence and pelvic organ prolapse before and after menopause. Which indicates that the reduction of estrogen receptors may be associated with stress urinary incontinence and pelvic organ prolapse closely. Key words: Vaginal wall; Estrogen receptor, Stress urinary incontinence; , Pelvic organ prolapse.

Pelvic Organ Prolapse (POP) Is A Complex Condition Often Associated With Both Urinary Incontinence And Urinary Retention. The Urodynamic Study Can Detect The Presence Or Absence Of Incontinence In Prolapse Patient & Type Of Surgery Appropriate For Particular Patient For Best Postoperative Outcome. Aims & Objectives: The aim of this study was to find out the voiding abnormalities among the prolapsed patient and to select the optimal surgical procedure in the individual patient based on the urodynamic findings. Methods: Fifty (50) patients attending gynaecology outdoor with any degree of pelvic organ prolapse fulfilling both inclusion and exclusion criteria are included in this study after taking proper written consent. Pessary test to detect occult stress urinary incontinence is performed. Routine investigation & USG were done. Then at urology department URODYNAMIC STUDY was performed. Transobturator tape surgery is used as an incontinence surgery. Results: Age distribution in our study population shows that maximum number (18, 36%) of patients were in the age group 61-70 years while minimum number (04, 08%) was noted in the age group above age group was found as above 70 years.Out of 50 patients only 40% of patient expressing symptom of SUI where as 60% patient had no symptom of SUI. 14% of patients in the study population attending in G&O OPD are in POP-Q stage II, stage III patient accounts for 54% while remaining 32% patients were in stage IV.Majority of patient (74%) of POP were suffering from stress urinary incontinence. Urge incontinence accounted for about 10% while 16% of patients had mixed form of incontinence.Our study showed 40% of patient of POP were suffering from overt stress urinary incontinence. And SUI could be detected in another 14% of prolapse patient after prolapse reduction by Pessary test.After doing Urodynamic study with prolapse reduction all prolapse patient with stress urinary incontinence could be detected. In the present study, incontinence surgery along with vaginal hysterectomy was done in 37 patients diagnosed stress urinary incontinence urodynamically. Only vaginal hysterectomy done in 13 patients diagnosed urge or mixed incontinence urodynamically.

Objective To explore quantity of typeⅠ and Ⅲcollagen and decorin(DCN) mRNA expression in the upper portion of the anterior vaginal wall in patients with pelvic organ prolapse (POP) and stress urinary incontinence(SUI). Methods Transvaginal biopsies were obtained from the anterior vaginal wall in 21 cases of POP(POP group), 20 cases of POP+ SUI(POP+ SUI group) and 17 cases of normal women (control group). The concentration of typeⅠand Ⅲ collagen were determined by ELISA method. RTQ-PCR was used to verify the level of DCN mRNA. Results The mean concentration extracellular matrix metabolism was significantly reduced in patients of POP group and POP+ SUI group, compared to control group(P 0.05). Conclusion A decrease in quantity of collagen type Ⅰ and Ⅲ in the connective tissue of anterior vaginal wall may compromise the tensile strength and flexibility, and result in an increase susceptibility to prolapse and stress urinary incontinence. To some extent, decorin might be involved in the pathogenesis of pelvic organ prolapse and stress urinary incontinence by influencing collagen metabolism in connective tissue of pelvic floor, and weaken their support strength and elastic properties.The pathogenesis of pelvic organ prolapse in post-menopausal women is complicated. Key words: pelvic organ prolapse(POP); stress urinary incontinence (SUI); collagen type Ⅰand Ⅲ; decorin(DCN)

Vaginal erosion after pubovaginal sling procedures using dermal allografts.

To investigate the necessity, safety and efficacy of transobturator tension-free vaginal tape (TVT-O) for treatment of stress urinary incontinence (SUI) during transvaginal corrective operation of pelvic organ prolapse (POP). From Jan. 2005 to Dec. 2010, 92 patients undergoing transvaginal pelvic reconstruction surgery for correction of POP concomitant TVT-O for treatment of SUI in Department of Obstetrics and Gynecology affiliated to Beijing Chaoyang Hospital as concomitant surgery group were enrolled in this retrospective study matched with 90 patients with mild SUI without SUI surgery as non-concomitant surgery group and 120 patients without SUI as control group.Variable clinical index, clinical efficacy and complications were compared among those three groups. Compared with those in the other two groups, the mean age [(62 ± 11) years] was lower (P = 0.007,0.038), the operation time only slightly increased (12.8 min and 12.9 min respectively) significantly in concomitant TVT-O group. The bleeding loss and the length of staying hospital after operation all exhibited no significant differences within three groups (P > 0.05). The effective rate for SUI was 96.7% (89/92) in concomitant TVT-O group, corrective operation of POP was ineffective for 74.4% (67/90) SUI, 9.2% (11/120) patients presented new SUI in the patients without SUI preoperatively. TVT-O is a simple, safe and effective method in the treatment of SUI, which is more suitable for performing simultaneously during the corrective operation of POP.Efficacy of SUI correction was limited in those patients undergoing only pelvic reconstructive surgery. However, a preventive anti-incontinence procedure is not recommended because of the lower incidence in POP patients without SUI preoperatively.

Objective To evaluate any changes in overall pelvic floor function among women with stress urinary incontinence (SUI). Methods Twenty-five female SUI patients were recruited as the SUI group and twenty-three healthy female counterparts were selected as the control group. Pelvic organ prolapse quantification (POP-Q) was performed with both groups. Ultrasonography was used to measure the position of the bladder neck, the posterior angle of the urethra, the urethra′s inclination angle and the size of the diaphragmatic hiatus for both groups at rest, during the Valsalva maneuver, as well as during the transition from resting to the Valsalva maneuver. The strength and fatigue of type I and type II fibers in the pelvic muscles were evaluated electrophysiologically, and anorectal manometry was also performed with both groups. The significance of any relationship between these measurements and SUI was determined using multivariate logistic regression analysis. Results Eleven members of the SUI group showed phase I pelvic organ prolapse. Twelve were in phase II and 2 were in phase III. All of those incidences were significantly different from the control group. There were significant differences between the two groups in the average bladder neck position, urethral inclination angle, posterior urethra angle, descending distance of the bladder neck, and urethral rotation angle during the Valsalva maneuver. In the transition from resting to the Valsalva maneuver, significant differences were found only in the distance of the bladder neck′s descent and the rotation angle of the urethra. The severity of pelvic organ prolapse, the descending distance of the bladder neck and the urethral rotation angle, as well as the bladder neck position and urethral angle during the Valsalva maneuver were the major risk factors associated with female SUI, and the correlation was statistically significant. Conclusion The greater the mobility of the bladder neck and urethra in female SUI patients, the more serious the prolapse. Prolapse, bladder neck mobility and urethral support all affect the overall functionality of the pelvic floor. Key words: Stress; Urinary incontinence; Pelvic floor; Ultrasonography; Anorectal manometry

Objective To explore the value of transperineal ultrasonography in diagnosis of female anterior pelvic cavity dysfunction. Methods From April to November 2014, a total of 68 cases of outpatients with frequent urination, urgency, dysuria and rotor of vagina who were primary diagnosed or suspected as anterior vaginal wall prolapse or uterine prolapse by pelvic organ prolapse quantitation (POP-Q) in the Department of Obstetrics and Gynecology of the First Affiliated Hospital of Guangzhou Medical University were enrolled as research objects. They were classified into two groups by transperineal ultrasound diagnosed results, anterior pelvic cavity dysfunction group (n=58) and normal anterior pelvic cavity function group (n=10). At the same time, according to whether patients in anterior pelvic cavity dysfunction group were combined with cystocele or not, they were classified into cystocele subgroup (n=28) and without cystocele subgroup (n=30). The parameters of resting and max Valsalva conditions were observed and measured, respectively by transperineal ultrasound, including bladder position, funneling of the internal urethral orifice, bladder neck-symphyseal distance (BSD), vesicourethral angle, the bladder neck descent (BND), rotation angle of urethra and bladder neck. And the cystocele subtypes of patients were classified. The BND, rotation angle of urethra and bladder neck, retrovesical angle of resting and max Valsalva conditions were compared between anterior pelvic cavity dysfunction group and normal anterior pelvic cavity function group, and with cystocele subgroup, and without cystocele subgroup, respectively by statistical methods. There were no statistical differences among the age, body weight, gravidity, parity and POP-Q degree between anterior pelvic cavity dysfunction group and normal anterior pelvic cavity function group, and with cystocele subgroup and without cystocele subgroup (P>0.05). The research followed the ethical standards of the human trials of the First Affiliated Hospital of Guangzhou Medical University, approved by the committee, and clinical research informed consent was signed by each patient. Results ①Among 68 cases of patients in this research, 58 cases of anterior pelvic cavity dysfunction diseases were diagnosed by transperineal ultrasound based on the position of bladder, BND, vesicourethral angle, rotation angle of urethra and bladder neck. All the 58 cases were stress urinary incontinence (SUI), and there were 10 cases with funneling of bladder neck, 28 cases with cystocele (7 cases with typeⅠ, 10 cases with type Ⅱ, 11 cases with type Ⅲ). The anterior pelvic cavity function of rest 10 cases all were normal. ②The average of vesicourethral angles of resting and max Valsalva conditions of 58 cases of patients in anterior pelvic cavity dysfunction group were 122.2° (113.3°-136.3°) and 137.7° (119.4°-159.2°), respectively, and both were larger than those of 10 cases in normal anterior pelvic cavity function group which was 91.2° (81.3°-99.0°) and 111.0° (88.3°-117.7°), respectively, and both the differences were statistically significant (Z=-3.775, P=0.000; Z=-3.152, P=0.002). But as to the BND, angle rotation of urethra and bladder neck between two groups, there were no statistical differences (P>0.05). ③The BND, rotation angle of urethra and bladder neck in the patients with cystocele subgroup were (26.4±7.3) mm, 64.0° (43.2°-78.9°), 67.7° (42.7°-84.5°), respectively, all were larger than those of patients without cystocele subgroups, which were (14.2±3.6) mm, 15.5° (10.1°-24.9°), 29.6° (26.4°-38.7°), respectively, and all the differences were statistically significant (t=9.090, P=0.000; Z=5.275, P=0.000; Z=5.322, P=0.000). But as to the retrovesical angles of resting and max Valsalva conditions in two subgroups, there were no statistical differences (P>0.05). Conclusions Transperineal ultrasound is a noninvasive, shortcut and more accurate method to observe the anatomical position and function of anterior pelvic cavity. It is useful for the diagnosis of female anterior pelvic cavity dysfunction, and has a great application value. Key words: Ultrasonography; Anterior pelvic cavity dysfunction; Urinary incontinence, stress