Persistent Perineal Pain Research Articles

Pre-therapeutical assessment of lower urinary tract symptoms in adult men: Systematic Review and clinical practice guidelines.

The aim was to propose initial and pre-therapeutical assessment of lower urinary tract symptoms in adult men through a systematic review and clinical practice guidelines Methods: These guidelines were based on a systematic review performed between January 2011 and November 2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. The protocol was registered in the International Prospective Register of Systematic Reviews database (CRD42022336418). The recommendations and the methodology of elaboration were prospectively validated by the French Health Authority (Haute Autorité de Santé - HAS). In total, 1662 publications were screened for eligibility and 311 met the inclusion criteria, 167 studies were retained among them 17 guidelines from French, European or International institutions. Perform on initial evaluation: identification of cardiovascular risk factors, metabolic syndrome, current medication, urinary and sexual symptoms (by structured interview or validated self-questionnaires), physical examination (lumbar fossa, pelvis, prostate, genitalia), urinalysis (dipstick or microscopy), abdominal ultrasound of the urinary tract (kidneys, bladder, prostate), post-void residual urine measurement (by ultrasound or automated measurement; under physiological conditions). Micturition flowmetry is recommended (except for general practitioners). Update and complete initial assessment before medication, interventional or surgical treatment if too old or incomplete. Perform a preoperative assessment (bleeding risk, infectious risk, geriatric risk). Urodynamic assessment, endorectal ultrasound and cystoscopy should not be systematically performed (only if additional information is needed). Perform urodynamics and urethrocystoscopy in case of failed interventional or surgical treatment. Following the initial workup, it is recommended to refer the patient to a urologist in case of: macroscopic hematuria, recurrent urinary tract infection or persistent perineal and/or suprapubic pain, persistent microscopic hematuria or leukocyturia in absence of urinary tract infection, predominant storage-phase symptoms, abnormal examination of the genitals or suspected prostate cancer, urinary retention, urinary tract stones, ureterohydronephrosis or morphological abnormalities of the prostate or the urinary tract. These guidelines aimed to define the recommended investigation for LUTS in adult men at diagnosis, before medical treatment and before surgical and interventional treatments, in order to better personalize management and avoid unnecessary and/or invasive examinations.

The Development and Content Validity of the Fremantle Perineal Awareness Questionnaire (FrePAQ) for Use in People With Persistent Perineal Pain

Background: Altered body awareness and perception comprise a common feature of persistent pain. The Fremantle Back Awareness Questionnaire (FreBAQ) was developed to assess body awareness and perception in people with back pain. There is no tool to measure these changes in people with persistent perineal pain. Objective: To develop the Fremantle Perineal Awareness Questionnaire (FrePAQ) to assess body awareness and perception in people with persistent perineal pain. To evaluate content validity using a qualitative survey. Study Design: Modified electronic Delphi and cross-sectional qualitative online survey. Methods: A focus group developed a draft questionnaire from the preexisting FreBAQ. A preliminary FrePAQ was developed through 3 Delphi rounds of anonymous voting by a panel of 14 experts. A qualitative survey was completed by individuals with persistent perineal pain to evaluate the comprehensiveness, comprehensibility, and relevance of the preliminary questionnaire. Responses were thematically analyzed, and demographic data were summarized descriptively. Results: Fourteen panel participants completed the Delphi study, with consensus achieved on a 9-item questionnaire after 3 rounds. One hundred thirty-five participants with persistent perineal pain completed the round 1 validation survey. Changes were made to the introduction and 7 items. A new group of 53 participants completed round 2, resulting in final changes to the introduction and 2 of the 9 items. Conclusions: An expert consensus was achieved in the wording of a new questionnaire aimed at assessing body awareness and perception in people with persistent perineal pain, which demonstrated acceptable content validity.

Switching from the transrectal to the transperineal route: A single center experience

IntroductionThis study aimed to evaluate the feasibility of switching from transrectal to transperineal prostate biopsy (TPPBx) by urologists with no previous experience with TPPBx.Material A monocentric clinical study with exhaustive and consecutive inclusions was conducted between January and November 2021, including 105 consecutive patients who underwent TPPBx performed by two senior urologists with no previous experience of TPPBx (GR, FB). Biopsies were performed under local anesthesia (LA) without antibioprophylaxis. The main objective was to assess the safety of this procedure. Adverse events were classified according to the Clavien-Dindo score. The secondary objectives were to assess the level of pain experienced during the different steps of the procedure using a numerating rating scale (NRS), the rate of clinically significant prostate cancer (csPCa) detected, and the level of anxiety using the Hospital Anxiety and Depression Scale (HAD). ResultsNo major complications (Clavien-Dindo score≥3) were reported. One patient presented with acute urinary retention (1%) and a urinary tract infection (1%). Other adverse events were hematuria (43%), hemospermia (23%), rectal bleeding (1%), perineal hematoma (3%), persistent perineal pain (5%), and de novo erectile dysfunction (2%). The median level of pain on NRS for the procedure was 2.00 (IQ: 1.00–4.00); it was 3.00 (IQ: 2.00–5.00) during LA and 3.00 (IQ: 2.00–5.00) during punctions. In anxious patients (HAD score>10), the level of pain during the procedure was 2.5 (IQ: 2.00–3.00). Overall, csPCa was detected in 63%. ConclusionTPPBx under LA without antibioprophylaxis provides few complications, an acceptable pain threshold, and a satisfactorily rate of csPCa detection, even if performed by urologists with no previous experience of TPPBx. Level of evidence3

Adjustable Transobturator Male System® (ATOMS) as a novel treatment for men with stress urinary incontinence in the United Kingdom

Objectives: To investigate the first experience in the United Kingdom of using the Adjustable Transobturator Male System® (ATOMS) in treating men with stress urinary incontinence (SUI). Methods: Between 2015 and 2021, 71 men (average age: 70.3, range: 50–81 years) were recruited and followed up. Of these, 67 (94%) had SUI secondary to a radical prostatectomy and 16 (23%) had previous radiotherapy post-prostatectomy. Seventy men underwent an insertion of ATOMS® under general anaesthetic. In one patient, due to his underlying morbid obesity, it was not possible to insert ATOMS and thus he was excluded from the study. Follow-up was up to 6 years (mean: 4 years, range: 2–6 years). Results: Out of 70 men, 53 (76%) were dry after ATOMS insertion (defined as using a maximum of one pad per day for reassurance only). Dryness was achieved within 6 months for 34/53 patients (range: 1–24 months). The average pad use was 3.4 pre-operatively and 0.7 post-operatively. Of the men who did not achieve dryness, 7/17 (41%) had previously undergone radiotherapy. There were 11 (16%) complications: two cases of infected device requiring removal, one case of balloon mechanism erosion requiring re-implantation, one case of balloon mechanism require repositioning, four cases of persistent perineal or scrotal pain, two cases of urinary retention and one case of a superficial wound infection treated medically. Overall, five devices were removed. Conclusions: The ATOMS appears to be a safe and efficacious treatment for men with SUI. Previous radiotherapy decreased the efficacy of ATOMS. Further studies on ATOMS with larger numbers of patients and longer follow-ups are required. In particular, establishing randomised control trials to confirm these positive outcomes as well as ascertain its long-term safety profile. Level of evidence: 4

A retrospective case series on transvaginal repair of rectovaginal fistula performed by a urogynaecology operative team in Australia.

Rectovaginal fistula (RVF) is an abnormal epithelialised connection between the rectum and vagina. It is a common condition in limited resource settings and is caused almost exclusively by obstetric injury. In contrast, RVF is uncommonly seen in high resource settings. This study aims to review the aetiology and effectiveness of RVF management in the high resource setting, identifying predictors for repair success and long-term outcomes. A retrospective case series study of patients who underwent transvaginal RVF repairs at two secondary healthcare facilities over a 14-year period by one operative group. A total of 41 patients underwent 46 surgical repairs. All patients presented with flatal and/or faecal incontinence and aetiology was identifiable in 78.0% (n=32). Obstetric cause was implicated in 26.8% (n=11) and other causes include 26.8% (n=11) from vaginal and abdominal surgery, 14.6% (n=6) from perianal abscess, 7.32% (n=3) as complications of Crohn's disease and 2.44% (n=1) as a complication of a cube pessary. Fistula was cured in 38 of 41 cases (92.7%) with a primary repair closure rate of 80.5% (n=33). Post-operative symptoms were limited to flatal incontinence in 4.88% (n=2), faecal incontinence in 2.44% (n=1), and persistent perineal pain in 7.32% (n=3). The success of the surgical repair was not significantly impacted by fistula size, aetiology, presence of a stoma for diversion, history of prior repair, duration since RVF formation or repair technique. This review identifies aetiology for RVF in the high resource setting and highlights the role of earlier surgical repair to minimise patient morbidity with good success in closure and reduction of post-operative symptoms.

Effects on Health-Related Quality of Life of Biofeedback Physiotherapy of the Pelvic Floor as an Adjunctive Treatment Following Surgical Repair of Cystocele.

Objectives: to demonstrate the benefits of physiotherapy (PT) with pelvic floor biofeedback (BFB) in improving health-related quality of life when used as a complementary therapy after surgical treatment of cystocele, in cases in which perineal pain or discomfort persists. Materials and methods: prospective observational study in 226 women who received complementary therapy after surgical treatment of cystocele due to persistent perineal discomfort or pain. Groups: GA (n = 78): women treated with 25 mg of oral pregabalin every 12 h plus BFB, consisting of 20 once-weekly therapy sessions, each 20 min long, with perineal pregelled surface electrodes connected to a screen which provides visual feedback; GB (n = 148): women treated with oral pregabalin 25 mg every 12 h without BFB. Variables: age, body mass index (BMI), time since onset of cystocele prior to surgery (TO), SF-36 health-related quality of life survey score, diseases and concomitant health conditions, follow-up time, success, or failure of postsurgical treatment. Results: average age 67.88 years (SD 12.33, 30–88), with no difference between GA and GB. Average body mass index (BMI) 27.08 (SD 0.45, 18.74–46.22), with no difference between GA and GB. Time since onset of cystocele prior to surgery (TO) was 6.61 years (SD 0.6), with no difference between GA and GB. Pretreatment SF-36 score was lower in GA success than GB success. Treatment was successful in 141 (63.20%) women and failed in 82 (36.80%). PT and age were the main predictors of success, and the least important were pretreatment SF-36 and the time elapsed after the intervention. In GA, 63 women (80.80%) showed improvement while 15 (19.20%) did not. Age was the main predictor of treatment success, while the least important was BMI. In GB, 78 women (53.80%) showed improvement while 67 (46.20%) did not improve. The main predictor was time since cystocele onset prior to surgery, while the least important was age. The odds ratio (OR) of improving quality of life for each unit increase in SF-36 was 11.5% (OR = 0.115) in all patients, with no difference between success and failure; in GA it was 23.80% (OR = 0.238), with a difference between success and failure; in GB it was 11.11% (OR = 0.111), with no difference between success and failure. GA and GB success had more history of eutocic delivery. GA success had more rUTI. GB success and GA failure both had more history of UI corrective surgery. The “failure” outcome had a higher number of patients with more than two concomitant pathological conditions. Conclusions: BFB as an adjunctive treatment improves quality of life in women suffering from persistent discomfort after surgery for cystocele. Young women who meet the criteria for recurrent urinary tract infection or who have a history of eutocic delivery show greater improvement. Body mass index does not influence response to treatment, while the presence of more than two concomitant conditions indicates a poor prognosis for improving quality of life.

A 10-year retrospective cohort study to assess objective and subjective outcomes of combined stapled transanal rectal resection and urogynecological surgery for pelvic floor dysfunction.

To assess the subjective and objective outcomes of combined stapled transanal rectal resection (STARR) and urogynecological surgery to treat pelvic organ prolapse, with a 10-year follow-up. This was a retrospective cohort study analyzing prospectively collected data from 53 consecutive patients who underwent combined stapled transanal rectal resection and urogynecological surgery, from 1 January 2005 to 31 December 2007 at a tertiary referral Pelvic Floor Unit of an Italian hospital. Fifty-three patients with a median age of 60years (interquartile range (IQR) 67-52t), underwent STARR and concomitant urogynecological surgery. No serious postoperative complications were recorded, and 37/53 women (70%) were evaluated at the 10-year follow-up visit. The cure rate was optimal in 34 women (64.1%). Regarding persistent and/or recurrent symptoms, five sexually-active patients (9%) reported dyspareunia only; obstructed defecation symptoms recurred in ten women (19%); urinary incontinence occurred in eight patients (15%); four patients (11%) reported persistent perineal pain; and two patients (5%) experienced both the urge to defecate and voiding dysfunction. At the 10-year follow-up, 14/27 patients (52%) stated that they would undergo the same operation again, if necessary. Furthermore, the survey found that patients would recommend the combined surgery. The 10-year results of this study proved that combined rectal and urogynecological surgery is well tolerated, associated with low morbidity, and more effectively treats a distressing and debilitating condition vs separate surgeries for rectal and pelvic organ prolapse. We recommend complementing the relatively small scale of this study with randomized trials involving a sufficient number of patients, to provide more conclusive evidence on the cumulative long-term effects of combined surgery vs 2- or 3-stage surgery.

Description and classification of postpartum chronic pain: A multicentric prospective study

IntroductionTo classify persistent perineal and pelvic postpartum pain using the classification usually employed in chronic pelvic pain. Material and methodProspective observational study including all women who have consulted an algologist or gynecologist at one of the six French centers for a chronic pain (superior or equal to 3 months) spontaneous linked by the mother with her childbirth were included. During semi-directed interviews, a questionnaire regarding sociodemographic factors and detailed questions about pain were collected. Then, pelvic and perineal pain were classified into 7 pain syndromes: pelvic sensitization (Convergences PP criteria), complex regional pain syndrome (Budapest criteria), pudendal or cluneal neuralgia (Nantes criteria), neuroma, thoraco-lumbar junction syndrome, myofascial pain (muscle trigger zone), fibromyalgia (American College of Rheumatology criteria). The principal objective of this study is to assess the prevalence of each painful disorder. The secondary aims were the description of socio-demographic factors and clinical characteristics of this population, identify the related symptoms and the impact on daily function associated with the chronic pelvic or perineal postpartum pain. Results40 women with chronic pelvic or perineal pain spontaneously linked with childbirth were included. 78 % experienced pain for more than 12 months. A large majority had a vaginal birth (95 %) with perineal suture (90 %) and severe acute pain within the first week postpartum (62 %). Postpartum pain impacted participant’s sexual activity (80 %), micturition (28 %) and defecation (38 %). In the sample, 17 cases of neuroma, 6 patients with pudendal or cluneal neuralgia, 13 patients with pelvic sensitization and 2 cases of fibromyalgia were identified. Complex regional pain syndrome was diagnosed in 8 patients, and myofascial pain in 11 women, and only 1 patient had thoraco-lumbar junction syndrome. Neuropathic pain was found in 31 participants (77.5 %) according to DN4 criteria. DiscussionThe classification scheme proposed in this study may be a very useful tool to investigate postpartum pelvic and perineal pain and to propose a treatment.

Episiotomy related morbidities measured using redness, edema, ecchymosis, discharge and apposition scale and numerical pain scale among primiparous women in Mulago National Referral Hospital, Kampala, Uganda.

Introductionepisiotomy induced inflammatory signs like redness, edema, ecchymosis and pain may remain beyond the period of hospitalization and can be objectively measured using redness, edema, ecchymosis, discharge and apposition (REEDA) scale. Pain in the postpartum period is a common problem and can be measured using the numerical pain scale (NPS). Episiotomy is normally poorly executed and poorly repaired with little attention to the subtle pain-free scar. Postpartum perineal pain has been found to affect more people with episiotomy compared to spontaneous perineal tears or contusion in the first two weeks. This study was aimed at comparing NPS and REEDA scores in the first two weeks of postpartum among primiparous parturients with or without episiotomy in Mulago National Referral Hospital.Methodsa prospective cohort study conducted by recruiting primiparous women systematically on the first postnatal day and categorizing them into episiotomy and no episiotomy group. NPS and REEDA scale were taken at baseline and 2 weeks postpartum.Resultsthe mean total REEDA score for primiparous women among the episiotomy group was significantly higher both on day 1 and day 14 with p-values <0.0001 and <0.0001 respectively as well as the day 14 mean NPS p-value 0.001.Conclusionepisiotomy, a traumatic obstetric procedure, that heals slowly and with persistent perineal pain compare to spontaneous perineal contusion or tears.

Is extralevator abdominoperineal resection necessary for low rectal carcinoma in the neoadjuvant chemoradiotherapy era?

Background: We aimed to compare the short-term surgical and early surgical oncological outcomes of abdominoperineal resection (APR) and extralevator APR (ELAPR) in patients with low rectal carcinoma that have received neoadjuvant chemoradiotherapy (NACRT), whose abdominal procedures were performed laparoscopically.Methods: One hundred and four patients who underwent APR or ELAPR for stage II/III low rectal carcinoma NACRT between 2013 and 2016 were evaluated by reviewing the standard charts for colorectal carcinoma.Results: Median follow-up for patients in APR group was 56 months(24–67 months) and 52 months(27–64 months) for ELAPR group. The postoperative complication rates were higher in ELAPR than in APR (perineal wound infection 38% vs. 22.5%(p = .03), perineal wound dehiscence 57% vs. 25%(p = .01), persistent perineal pain 28.5% vs. 13%(p = .01), urinary dysfunction 23% vs. 14.5%(p = .02), reoperation 16.5% vs. 4.8%(p = .03), respectively). Circumferential resection margin positivity, the number of lymph nodes dissected, and the rate of intra-operative perforation of the tumor were similar for both surgical techniques. Local recurrence rates at postoperative 2 years were also similar after APR and ELAPR (8% vs. 9.5%, p = .2).Conclusion: We conclude that in the era of routinely used NACRT, ELAPR is not superior to conventional APR for stage II/III low rectal carcinomas. ELAPR is associated with increased morbidity and has no short-term surgical oncological advantage over APR.

Clinical outcomes of stapled transanal rectal resection for obstructed defaecation syndrome at 10-year follow-up.

The long-term efficacy of stapled transanal rectal resection (STARR) for surgical management of obstructed defaecation syndrome (ODS) has not been evaluated. Therefore, we investigated the long-term efficacy (>10years) of STARR for treatment of ODS related to rectocele or rectal intussusception and the factors that predict treatment outcome. This study was a retrospective cohort analysis conducted on prospectively collected data. Seventy-four consecutive patients who underwent STARR for ODS between January 2005 and December 2006 in two Italian hospitals were included. Seventy-four patients [66 women; median age 61 (29-77) years] underwent STARR for ODS. No serious postoperative complications were recorded. Ten years postoperatively, 60 (81%) patients completed the expected follow-up. Twenty-three patients (38%) reported persistent perineal pain and 13 (22%) experienced the urge to defaecate. ODS symptoms recurred in 24 (40%) patients after 10years. At the 10-year follow-up, 35% of patients were very satisfied and 28% would recommend STARR and undergo the same procedure again if necessary. In contrast, 21% of patients would not select STARR again. Previous uro-gynaecological or rectal surgery and high constipation scores were identified as risk factors for recurrence. Stapled transanal rectal resection significantly improves the symptoms of ODS in the short term. In the long term STARR is less effective, however.

Adenoid Cystic Carcinoma of Bartholin’s Gland Misdiagnosed as Benign Vulvar Adnexal Tumour

Adenoid cystic carcinoma of the Bartholin’s gland accounts for < 1% of all female genital malignancies and 1–7% of all vulvar carcinomas. These tumours are slow growing and characterized by perineural and lymphatic invasion leading to pain and recurrence seen with this tumour. Adenoid cystic carcinoma of the Bartholin’s gland is rare, and the diagnosis may be delayed or missed by both the clinicians and pathologists as in this case. Persistent perineal pain along with a vulvar mass should raise the suspicion. We report a case of adenoid cystic carcinoma of Bartholin’s gland misdiagnosed as a benign vulvar adnexal tumour at initial evaluation and biopsy. The patient had persistence of pain due to which she returned to her physician 1 year later. At that time, a histopathological review of the previous biopsy was done which revealed adenoid cystic carcinoma of the Bartholin’s gland. The patient was treated with radical vulvectomy with ipsilateral inguinofemoral lymphadenectomy. The entire Bartholin’s gland was excised by dissecting deep into the ischiorectal fossa. Part of the distal vagina was also excised. Patient was given post-operative external beam radiotherapy with concurrent chemotherapy with carboplatin. A high index of suspicion is required to avoid delay in diagnosis and management. A deep and wide dissection in the ischiorectal fossa is necessary for complete excision of the tumour.

Nonabsorbable polymer clip as a cause of chronic perineal pain after radical prostatectomy: Description of a case treated by transperineal approach

The occurrence of persistent perineal pain caused by surgical clips has rarely been described after radical prostatectomy (RP). We describe the case of a patient complaining of chronic perineal pain occurred soon after robotic RP, refractory to conventional medical therapy and exacerbated by the sitting position. Pain was related to a nonabsorbable polymer clip used to secure lateral pedicles. A transpeerineal approach was used to perform an hydrodissection of the rectovesical space at the level of the surgical clip combined with local injection of mepivacaine and betametasone. The patient experienced a clinically significant reduction of pain that remained stable at three months' follow-up.

Antenatal Perineal Massage Improves Women’s Experience of Childbirth and Postpartum Recovery: A Review to Facilitate Provider and Patient Education on the Technique

Vaginal delivery during childbirth is associated with perineal trauma and damage in most women. Perineal damage during delivery can have significant long-term consequences for women, including decreased quality of birthing experience, persistent postpartum perineal pain and sexual dysfunction, as well as pelvic floor pathology. Many women fear such perineal trauma. In fact, obstetrical perineal damage and its long term consequences are some of the greatest concerns of patients. Even though evidencebased outcomes show antenatal perineal massage (APM) is an effective tool to reduce perineal trauma at childbirth, education of pregnant women about and subsequent application of the intervention remains low. This review details the potential physicaland psychological benefits of APM for most women, with a focus on helping the providers educate women and staff on the technique. Additionally, the impact of partner involvement in APM is discussed. Potential discussion topics are provided, to help care providers explain the benefits of APM to their patients. Revised, more flexible patient instructions for APM are also proposed. A discussion of vaginal physiology with regard to product choice during APM is reviewed. In spite of the mention of APM in many modern medical practice guidelines, detailed information to help providers teach the techniqueand to encourage patient adoption is lacking. This review provides information to make APM a more accessible choice for providers and women in order to decrease chances of perineal damage during childbirth, along with related long-term morbidities, which can deleteriously impact the patients’ quality of life.

Association of Pain Catastrophizing with the Incidence and Severity of Acute and Persistent Perineal Pain after Natural Childbirth: Longitudinal Cohort Study

Background and objectives Vaginal birth delivery may result in acute and persistent perineal pain postpartum. This study evaluated the association between catastrophizing, a phenomenon of poor psychological adjustment to pain leading the individual to magnify the painful experience making it more intense, and the incidence and severity of perineal pain and its relationship to perineal trauma.Method Cohort study conducted with pregnant women in labor. We used the pain catastrophizing scale during hospitalization and assessed the degree of perineal lesion and pain severity in the first 24hours and after 8 weeks of delivery using a numerical pain scale.Results We evaluated 55 women, with acute pain reported by 69.1%, moderate/severe pain by 36.3%, and persistent pain by 14.5%. Catastrophizing mean score was 2.15 ± 1.24. Catastrophizing patients showed a 2.90 relative risk (RR) for perineal pain (95% CI: 1.08-7.75) and RR: 1.31 for developing persistent perineal pain (95% CI: 1.05-1.64). They also showed a RR: 2.2 for developing acute and severe perineal pain (95% CI: 1.11-4.33).Conclusions The incidence of acute and persistent perineal pain after vaginal delivery is high. Catastrophizing pregnant women are at increased risk for developing acute and persistent perineal pain, as well as severe pain. Perineal trauma increased the risk of persistent perineal pain.

Results of extralevator abdominoperineal resection for low rectal cancer including quality of life and long-term wound complications

Extralevator abdominoperineal resection (APR) for low rectal cancer has been adopted by centers to improve oncological outcome. The present study aimed to investigate oncological results, wound complications, and quality of life (QoL). Patients who underwent extralevator APR for rectal cancer between 2007 and 2011 were identified retrospectively. QoL status was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-CR30 and CR29 questionnaires. Thirty laparoscopic (n = 7) or open (n = 23) extralevator APRs were performed in 17 male and 13 female patients. The mortality was zero; circumferential margin involvement occurred in two cases (6.7 %); and there was no bowel perforation. No local recurrence was noted after a median follow-up of 28.3 months; however, six patients died, and eight developed distant metastases. Perineal wound complications were found in 46.6 % of patients, and all were managed conservatively. Fifty percent of the patients reported persistent perineal pain at the follow-up exam. QoL was assessed 7 to 46 months after surgery, and the global health status (70.6) was comparable to the EORTC reference group and published conventional APR series. The QLQ-CR29 module revealed high mean symptom scores for urinary frequency (48.1), incontinence (30.5), and impotence (79.1). Extralevator APR can control local recurrence but not distant metastases of low rectal cancer. The extended perineal resection appears not to decrease general QoL, but it results in a high rate of perineal wound complications. Genitourinary functions are often impaired, even in the long term, and further improvements to the technique must seek to reduce genitourinary harm.

The Retrourethral Transobturator Sling Suspension in the Treatment of Male Urinary Stress Incontinence: Results of a Single Institution Experience

Objective. To evaluate functional outcome of the retrourethral transobturator sling suspension (RTS) in the treatment of stress urinary incontinence (SUI) caused by prior prostate surgery. Methods. The RTS (AdVance male sling) was implanted in 32 patients who suffered from mild to severe postsurgical-treatment incontinence at the University Hospital Ulm from September 2010 to September 2011 including 10 patients with prior radiation therapy. Functional data (uroflowmetry, daily pad use, and postvoid residual urine) as well as quality of life with impact of urinary problems (ICIQ-UI SF) were prospectively assessed at baseline and during followup. Results. After a median followup of 9 months (range, 3–14) the incontinence cure rate (no pad usage) was 56.2% and the improvement rate (1-2 pads/day or ≥50% reduction) was 21.9%. No improvement was observed in 21.9%. Daily pad use and ICIQ-UI SF score improved significantly. No major perioperative complications occurred. Postoperatively, 15.6% of the patients exhibited transient acute urinary retention which resolved without further treatment after a maximum of 3 weeks. One patient underwent sling explantation due to dislocation and persistent perineal pain. Conclusions. The implantation of the RTS is a safe and effective procedure in selected patients with SUI resulting from prostate surgery.

Angiomyofibroblastoma: a rare vulvar tumor

Angiomyofibroblastoma is a rare, benign mesenchymal tumor that occurs mainly in the vulval region of middle age (35-45years) women. We describe a 41-year-old woman, presenting with a 10-cm right vulvar mass and persistent perineal pain lasting 1month. A surgical excision of the lesion was performed and a large mass with an intact capsule was sent for pathological examination. The results indicated angiomyofibroblastoma. The differential diagnosis between angiomyofibroblastoma (AMF) and aggressive angiomyxoma (AAM) is very important because prognoses are not the same. AMF is a well-circumscribed lesion, with a weak risk of local non-destructive recurrence. AAM is a locally aggressive and infiltrative neoplasm, with a high risk of local aggressive recurrence. Wide excision with a rim of normal tissue is recommended in all cases of vulvar tumors.

Efficacy of the InVance™ Male Sling in Men with Stress Urinary Incontinence

ObjectivesTo evaluate the efficacy and safety of the InVance™ bulbourethral sling in male stress urinary incontinence. Materials and methodsBetween June 2003 and April 2005, the InVance™ bulbourethral sling was implanted into 50 patients with urinary incontinence after prostate surgery in 49 cases and pelvic trauma in 1 case. The patients were monitored and evaluated in a prospective manner (continence, tolerance, and satisfaction). The treatment was considered to be successful if the patient stopped wearing any kind of continence pad (patient cured) or only one pad per day (patient improved), with no de novo urinary disorders and without significant postvoid residual urine. Patient satisfaction with the procedure was assessed. ResultsAfter a median follow-up of 6 mo, 50% of patients were dry, 26% had improved, and 24% suffered treatment failure. The success rates for the patients with severe incontinence and those who had undergone radiation therapy were 50% and 25%, respectively. All patients who were dry or had improved were satisfied and presented no obstructive or irritative de novo urinary disorders. The overall success rate for the 51 procedures conducted was 74.5%. Six cases of transitory acute urine retention and six cases of persistent perineal pain were reported. Explantation was necessary because of suppuration of the sling in three patients and of a de novo irritative urinary disorder in one patient. No cases of pubic osteitis or urethral erosion were reported. ConclusionsThe InVance™ bulbourethral sling procedure makes it possible to treat stress urinary incontinence after prostate surgery with satisfactory and lasting short-term results. Severe incontinence and a past history of pelvic radiation therapy seem to be factors contributing to the failure of this procedure.

Poster 28: The Effect of Genital Tract Trauma on Pelvic Floor Function After Childbirth

OBJECTIVE: The objective of this study was to describe the impact of genital tract trauma on the prevalence of perineal pain, urinary (UI) and anal incontinence (AI), and sexual function in a low-risk cohort of women after vaginal birth. METHODS: In this prospective cohort study, women completed validated questionnaires at discharge, 6 weeks and 3 months postpartum. Questionnaires included the Modified McGill pain scale, Incontinence Impact Questionnaire (IIQ-7), Fecal Incontinence Score (FIS), and Intimate Relationship Scale (IRS). Intrapartum events were recorded and trauma was mapped to site (anterior or perineal) and severity (major or minor). Chi-squared analyses were used to compare subgroups. Significance was set at P<0.05. RESULTS: Five hundred thirteen women participated with follow-up rates of 96% postpartum day 1, 63% at 6 weeks, and 57% at 3 months. Mean age was 24.8 ± 5.2 years and 40% were nulliparous. Less than 1% of women underwent episiotomy or operative vaginal delivery or had recognized third- or fourth-degree lacerations. Twenty percent of women delivered without trauma, 34% with anterior (periurethral, periclitoral, or labial), 17% perineal, and 26%with both anterior and perineal trauma. Major trauma (trauma that involved perineal muscles or required suturing) occurred in 19%. At 3 months, few women (1%) had persistent perineal pain. AI (FIS score >0) was reported by 28% of women at 6 weeks and 24% at 3 months. Women with major trauma were more likely to report AI at 3 months (P=0.004), but presence or site of trauma was not related to AI complaints (all P=not significant [NS]). Complaints of UI were common at 28% at 6 weeks and 30% at 3 months. Fewer women reported IIQ-7 scores >0, at 17% and 12%, respectively. UI was not related to the presence or severity of trauma (all P=NS). Women with anterior trauma had fewer UI complaints than women with other sites of trauma (P=0.02). Dyspareunia was reported more often by women with major trauma than women with minor or no trauma (P=0.02). At 6 weeks, UI and AI were positively associated with directed forceful pushing in the second stage (P=0.003 and P=0.02, respectively). At 3 months, AI and UI were not associated with age, race/ethnicity, parity, body mass index, length of second stage, fetal weight, oxytocin or epidural use, or maternal position at delivery. CONCLUSIONS: This is the first prospective cohort study of low-risk healthy women that examines the impact of genital tract trauma on postpartum pelvic floor function. Complaints of pain were rare; AI and UI were reported more commonly. UI was inversely associated with anterior trauma, whereas AI was associated with perineal laceration. Directed forceful pushing in the second stage of labor may place women at risk in the short term for pelvic floor disorders.