Pelvic Organ Prolapse Stage Research Articles

A comparative study of laparoscopic sacrocolpopexy and total vaginal mesh procedure using lightweight polypropylene meshes for prolapse repair

ObjectiveUse of vaginal meshes for treatment of pelvic organ prolapse (POP) remains controversial. A trend toward abdominal approaches and the development of new meshes has been noted. We compared the 1-year results of two different approaches using new lightweight meshes. Materials and methodsSixty-nine (95.8%) of 72 women with POP Stage ≥ 2, who underwent laparoscopic sacrocolpopexy (LSC) (n = 39) or a total vaginal mesh (TVM) procedure (n = 30) using lightweight polypropylene meshes, were studied. Baseline and follow-up assessments included a pelvic examination and a composite condition-specific questionnaire. A detailed comparison of 1-year outcomes was made. Data were analyzed using appropriate statistical methods. ResultsCompared to the TVM group, the LSC group was characterized by a younger age (53.7 years vs. 64.1 years, p < 0.001) and a longer operating time (264 minutes vs. 177.6 minutes, p < 0.001). Objective anatomic success (POP Stage ≤ 1) rates were similar between groups after statistical adjustment, i.e., 84.6% (33/39) and 86.7% (26/30) after LSC and TVM (p = 0.94), respectively. However, the dominant recurrence sites were different with anterior (n = 6) most frequent after LSC and apical (n = 4) most frequent after TVM. Reoperations were needed for the four (13.3%) apical recurrences in the TVM group. No serious complications were noted. We found “cystocele as the dominant prolapse” (p = 0.016; odds ratio = 6.94) and “suspension of prolapsed (POP Stage ≥ 2) uterus” (p = 0.025; odds ratio = 7.00) significantly affected recurrence after LSC and TVM, respectively. ConclusionPOP repair by LSC or TVM using the new lightweight polypropylene meshes seems to be safe and has comparable outcomes, but limitations may vary.

Quantitative assessment of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse using support vector machines.

The objective of this study was to quantitatively assess the ability of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse. New measurements representing pelvic structural characteristics are proposed and analyzed using support vector machines (SVM). This retrospective study used data from 207 women with different types and stages of prolapse. Their demographic information, clinical history, and dynamic MRI data were obtained from the database. New MRI measurements were extracted and analyzed based on these reference lines: pubococcygeal line (PCL), mid-pubic line (MPL), true conjugate line (TCL), obstetric conjugate line (OCL), and diagonal conjugate line (DCL). A classification model using SVM was designed to assess the impact of the features (variables) in classifying prolapse into low or high stage. The classification model using SVM can accurately identified anterior prolapse with very high accuracy (>0.90), and apical and posterior prolapse with good accuracy (0.80 - 0.90). Two newly proposed MRI-based features were found to be significant in the identification of anterior and posterior prolapse: the angle between TCL and MPL for anterior prolapse, and the angle between DCL and PCL for posterior prolapse. The overall accuracy of posterior prolapse identification increased from 47% to 80% when the newly proposed MRI-based features were taken into consideration. The proposed MRI-based measurements are effective in differentiating low and high stages of pelvic organ prolapse, particularly for posterior prolapse.

Midpubic Line to Stage Pelvic Organ Prolapse by MRI Defecography As Compared to POP-Q

Objective: To compare the degree of pelvic organ prolapse (POP) as measured by the pelvic organ prolapse quantification (POP-Q) system to the degree of prolapse as measured by magnetic resonance imaging (MRI) defecography and to merge clinical and radiologic terminology in reference to POP. Methods: A retrospective analysis of 29 patients who presented with POP and defecatory complaints and underwent MRI defecography (2008-2011). POP-Q scores were recorded by two attending urogynecologists. A radiologist, blinded to the clinical POP-Q scores, measured the maximum prolapse of the anterior vagina, posterior vagina, and vaginal apex/cervix on each subject’s MRI. Results: Prolapse as measured by MRI defecography was significantly more advanced as compared to the clinical POP-Q measurements in all three compartments studied. The differences were both statistically significant and potentially, clinically relevant. A mean difference of 2.0 centimeters ± 1.5 SD, 2.3 centimeters ± 2.7 SD, and 5.0 centimeters ± 2.0 SD was observed in the anterior, apical, and posterior vaginal compartments, respectively.

Measuring the quality of care provided to women with pelvic organ prolapse

Health care providers are increasingly being evaluated bythe quality of care they provide. Our aim was to assess the feasibility of recently developed quality indicators (QIs) for pelvic organ prolapse (POP) and identify possible deficits in care. A panel ranked 14 QIs based on the RAND appropriateness method assessing screening and diagnosis, pessary management, and surgery for POP. Retrospective chart abstraction was performed after identifying patients with a diagnosis of POP evaluated within a hospital-based multispecialty group using International Classification of Diseases, ninth edition, diagnosis codes. Of 283 patients identified, 98% of those with a new complaint of vaginal bulge had a pelvic examination. The POP was described but not staged in 6% and not documented at all in 25.1%. Among those managed with pessaries, 98% had vaginal examinations at least every 6 months. Forty-nine percent of the patients who had surgery had complete preoperative POP staging. Only 20% of women undergoing apical surgery had documentation of counseling regarding different surgical options, and of the women who underwent a hysterectomy for POP, only 48% had a concomitant vault suspension. Although 71% had documentation about the risk of postoperative stress incontinence, only 14.5% had documented counseling regarding risks of mesh. Only 37% of patients implanted with mesh forPOP had documented follow-up at 1 year. An intraoperative cystoscopy was performed in 86% undergoing cystocele repair or apical surgery. The quality of care for women with POP can be feasiblymeasured with QIs. Processes of care were deficient in many areas, and our findings can serve as a basis for quality improvement interventions.

Effect of Bladder Volume on Staging of Pelvic Organ Prolapse Using POPQ and Dynamic MRI

Effect of Bladder Volume on Staging of Pelvic Organ Prolapse Using POPQ and Dynamic MRI

Estudio urodinámico en mujeres con síntomas de incontinencia urinaria de esfuerzo pura

ObjectiveTo describe the results of urodynamic study in women with pure stress urinary incontinence symptoms, including the characteristics of the overactive detrusor. No other clinical assessments were taken into account. Material and methodsA retrospective study in women with urinary incontinence consecutively evaluated by urodynamic study. From a total of 710 women, only 108 (15%) with pure stress urinary incontinence symptoms were selected. Women with prior urinary incontinence surgery, pelvic organ prolapse (stage≥iii), pelvic radiotherapy, using medication active on the lower urinary tract and neurological diseases were excluded. Infusion rate was 70ml/min. Detrusor overactivity was induced only by cough. A standardized cough stress test with progressive cough intensity was carried out. ResultsReference urodynamic values for stress incontinent women are described. Urodynamic stress incontinence was observed in 79 women (73.1%), detrusor overactivity in 4 (3.7%) and mixed urodynamic diagnosis in 15 (13.8%). Test was inconclusive in 10 patients (9.2%). Two women had detrusor overactivity incontinence (1.9%). One patient had detrusor overactivity induced by cough without urodynamic stress incontinence (0.9%). There was an association between detrusor overactivity and nocturia≥2 (P=.002; odds ratio: 3.74; 95% confidence interval: 1.22-11.39). One woman had a bladder outlet obstruction (0.9%). ConclusionsIn women with pure stress urinary incontinence, without knowing the outcome of other clinical assessments, urodynamic study can provide useful information to define the proper therapy.

Factors that affect early recurrence after prolapse repair by a nonanchored vaginal mesh procedure

ObjectiveProsima (Ethicon, Somerville, NJ, USA) is a novel procedure for treating pelvic organ prolapse (POP) that uses nonanchored vaginal mesh. However, nonfixation of the mesh may limit effectiveness. The aim of this study was to evaluate the safety, efficacy, and limitations of this procedure. Materials and methodsFrom January 2011 through to December 2011, 52 patients with symptomatic POP ≥ Stage 2 undergoing the Prosima procedure at a tertiary hospital were enrolled consecutively in this prospective study. A Data and Safety Monitoring Plan (DSMP) was developed to assess the results. ResultsFifty of the 52 patients (96%) attended the 3–6-month postoperative assessment. Symptom and quality-of-life scores were found to have improved significantly after surgery (p < 0.05). Forty-two patients (84%) underwent successful treatment for POP (Stage 0-1). The other eight patients (16%) were found to have recurrent Stage 2 anterior vaginal wall prolapse, although most of them (5/8) were asymptomatic. The highest morbidity, namely vaginal mesh exposure, occurred in four patients (8%) and was managed as a minor issue. Statistical analysis showed that anatomic recurrence was significantly (p < 0.05) associated with a “preoperative Ba ≥ +4 cm” (odds ratio = 20.57), “conservation of the prolapsed uterus” (odds ratio = 10.56) and “use of a concomitant midurethral sling” (odds ratio = 0.076). ConclusionProsima seems to have limitations when used to manage severe anterior vaginal wall prolapse and concomitant surgery may further affect its effectiveness. The information obtained from this study's DSMP will contribute to developing a strategy to improve the use of nonanchored vaginal mesh for POP repair.

Pelvic floor dysfunction after levator trauma 1-year postpartum: a prospective case-control study.

The aim of this study was to evaluate pelvic floor dysfunction and anatomical signs of pelvic organ prolapse (POP) in patients with levator ani muscle (LAM) trauma compared with patients with an intact LAM 1 year postpartum. In a prospective case-control study, primiparous women after vaginal delivery, with LAM trauma diagnosed on 3D ultrasound, were included in the case group. Controls consisted of patients who fulfilled the same inclusion criteria but had an intact levator. All women were investigated 1 year postpartum in respect of bladder, bowel, prolapse, and sexual function using the Australian Pelvic Floor Questionnaire. POP was assessed according to the Pelvic Organ Prolapse Quantification (POP-Q) system and pelvic floor muscle strength using the Oxford Grading Scale. Forty patients were included: 20 with and 20 without levator trauma. Urinary symptoms were significantly more frequent in women with LAM trauma compared with controls (p = 0.01). The two groups were comparable in respect of bowel, sexual, and prolapse symptoms (p = 0.24, p = 0.60, p = 0.99 respectively). Unlike POP stages II and III, POP stage I was significantly more common in LAM trauma patients (n = 19, 95 %) than in controls (n = 10, 50 %) (p =0.003). A positive association was noted between POP stage I and LAM trauma (RR = 7.2). The involvement of multiple compartments was significantly more frequent in cases than in controls (p = 0.003). Except for urinary symptoms, LAM trauma was asymptomatic in nearly all patients 1 year postpartum. However, POP stage I involving multiple compartments occurred more frequently in LAM trauma patients than in controls.

Anterior-Apical Single-Incision Mesh Surgery (SIMS): Surgical and Functional Outcomes at 1 Year

Study ObjectivesTo study the surgical and functional outcomes of single-incision mesh surgery for treatment of advanced pelvic organ prolapse (POP). DesignCase series (Canadian Task Force classification II-3). SettingUniversity hospital. PatientsSixty-five patients who underwent surgery to treat symptomatic POP greater than stage II according to the Pelvic Organ Prolapse Quantification System (POP-Q). InterventionAll patients underwent anterior-apical single-incision mesh surgery using the Elevate Anterior and Apical Prolapse Repair System. Measurements and Main ResultsThe primary objectives were anatomical correction of anterior and apical prolapse of POP stage I or greater and absence of voiding dysfunction reported via multi-channel urodynamic study at 6 months after surgery. Subjective outcome was measured via patient feedback using questions 2 and 3 of the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6). The secondary outcome was quality of life using the following: Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire 7 (IIQ-7), POPDI-6, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Two-dimensional introital ultrasonography was performed in the first and third months after surgery and at 1-year follow-up. Descriptive statistics were used for demographic and perioperative data. The paired-samples t test was used for comparison of preoperative and postoperative continuous data. For all comparisons, a value of p < .05 was considered statistically significant. All statistical methods were performed using commercially available software (SPSS version 17). Postoperative data were available for 64 patients. The objective outcome was 96.9%, and the subjective outcome was 93.8%. All patients demonstrated significant improvement in anatomical outcomes after prolapse surgery (p < .05), and none experienced recurrence requiring further surgery. There was concomitant significant improvement in POPDI-6, UDI-6, IIQ-7, and PISQ-12 scores after surgery. A subanalysis of POP quantification measurements immediately after surgery and at 1-year postoperative follow-up demonstrated deepening of the C point and total vaginal length. Ultrasound evaluation demonstrated a significant increase in the length and thickness of mesh at 1-year follow-up. There has been no documented mesh extrusion to date. However, the number of patients with stress urinary incontinence has increased. Four patients received treatment, whereas in the remaining patients the condition was not severe enough to require surgical intervention. ConclusionsSingle-incision mesh surgery for treatment of advanced POP results in improvement in anatomical and quality-of-life outcomes. No mesh exposure was recorded in the first year after surgery; however, new onset of stress urinary incontinence may occur. Ultrasound evaluation demonstrated an increase in mesh length and thickness over time, with concurrent calculated lengthening of the C point and total vaginal length.

Postpartum pelvic floor muscle training and pelvic organ prolapse—a randomized trial of primiparous women

Pelvic organ prolapse (POP) is a common and distressing condition. The aim of the present study was to evaluate the effect ofpelvic floor muscle training (PFMT) on prevention and treatment ofsymptoms and signs of POP in primiparous postpartum women. This was a parallel group assessor blind randomized controlled trial. One hundred seventy-five primiparous postpartum women, mean age 29.8 years (standard deviation 4.1), stratified on major levator ani defects or no defect diagnosed by 3-/4-dimensional ultrasound, participated in a 4-month PFMT starting at 6-8 weeks' postpartum or control. All participants had thorough individual instruction and assessment of ability to perform correct pelvic floor muscle contractions. The PFMT group followed a supervised, weekly group training program and performed 3 sets of 8-12 daily maximal contractions at home. Main outcome was POP stage II or greater assessed by POP quantification and bladder neck position assessed by 3-/4- dimensional transperineal ultrasonography. Secondary outcome was symptoms of vaginal bulge using International Consultation on Incontinence Vaginal Symptoms questionnaire. Ninety-six percent of the intervention group adhered to ≥80% of both group and home training sessions. At postintervention, there was no significant risk difference in POP (rational ratio, 1.62; 95% confidence interval, 0.55-4.75), bladder neck position or symptoms of vaginal bulging. No effect was found of postpartum PFMT on POP in primiparous women. More randomized controlled trials are needed before strong conclusions can be drawn on the effect of PFMT on POP in the particular population.

MP33-17 CONTEMPORARY COMPARISON BETWEEN RETROPUBIC MID URETHRAL SLING (MUS) AND AUTOLOGOUS PUBOVAGINAL SLING (PVS) FOR STRESS URINARY INCONTINENCE (SUI) AFTER THE FDA ADVISORY WARNING

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence Therapy I1 Apr 2014MP33-17 CONTEMPORARY COMPARISON BETWEEN RETROPUBIC MID URETHRAL SLING (MUS) AND AUTOLOGOUS PUBOVAGINAL SLING (PVS) FOR STRESS URINARY INCONTINENCE (SUI) AFTER THE FDA ADVISORY WARNING Stephen Mock, Jonathan Angelle, W. Stuart Reynolds, David J. Osborn, Roger R. Dmochowski, and Alexander Gomelsky Stephen MockStephen Mock More articles by this author , Jonathan AngelleJonathan Angelle More articles by this author , W. Stuart ReynoldsW. Stuart Reynolds More articles by this author , David J. OsbornDavid J. Osborn More articles by this author , Roger R. DmochowskiRoger R. Dmochowski More articles by this author , and Alexander GomelskyAlexander Gomelsky More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.968AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES At present, synthetic MUS is widely considered to be the standard of care for female SUI and has largely replaced the PVS, a traditionally more morbid procedure. In light of the 2011 FDA warning on mesh use for pelvic organ prolapse (POP), concerns regarding mesh use, in general, have been raised by both patients and providers. As a result, fewer patients may be opting for mesh. The aim of this study is to compare efficacy and complication rates in a cohort of women who were offered either procedure after the FDA warning and made an informed decision on procedure option. METHODS A total of 201 women underwent either PVS or MUS after the FDA warning was issued in July 2011. Exclusion criteria included prior anti-incontinence surgery, concomitant surgery other than hysterectomy, and POP stage>2. Patients were followed prospectively with validated quality of life (QoL) questionnaires and subjective SEAPI (stress, emptying, anatomy, protection, inhibition) scores. Treatment success was defined as absence of subjective or objective SUI. Peri-operative complications were classified via the Clavien-Dindo scale. RESULTS Minimum follow-up was 12 months (mean 14.6). Ninety one (45%) and 110 (55%) women opted for PVS and MUS, respectively. Preoperative demographics and clinical parameters, including age, body mass index, parity, pad usage, mean abdominal leak point pressure, severity of concomitant POP, SEAPI scores, and mean QoL indices did not differ significantly between the groups. There was no difference in the proportion of women undergoing concomitant hysterectomy (52.7% vs. 50%, p=0.7). Treatment success was similar (75.8% vs. 80.9%, p=0.38) and there was no difference in rates of postoperative voiding dysfunction (1.1% vs. 1.8%, p=0.68) or de novo urgency incontinence (4.4% vs. 4.5%, p=0.96). Length of hospitalization did not significantly differ (1.18 vs. 1.16 days, p=0.9). There was no difference in the occurrence of Clavien-Dindo surgical complications between the two groups (6.6% vs. 10%, p=0.39). CONCLUSIONS Since the 2011 FDA warning, more women are forgoing the use of mesh in the treatment of SUI. In a contemporary cohort of women considered suitable candidates for either sling, both procedures offer comparable efficacy and complication rates. PVS may be safely offered to patients who would otherwise be good candidates for MUS if they are concerned with the implantation of mesh. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e344-e345 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Stephen Mock More articles by this author Jonathan Angelle More articles by this author W. Stuart Reynolds More articles by this author David J. Osborn More articles by this author Roger R. Dmochowski More articles by this author Alexander Gomelsky More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Association between susceptibility to advanced pelvic organ prolapse and glutathione S-transferase P1 Ile105Val polymorphism

ObjectiveOxidative stress is associated with the pathogenesis of pelvic organ prolapse (POP). Because glutathione S-transferases (GSTs) are the major detoxification enzymes which protect cells against oxidative stress, genetic variations in the GST gene may modulate the risk of POP. This study aimed to determine the association between advanced POP and the polymorphisms of GSTM1, GSTT1 and GSTP1 (rs1695). Study designThis is a hospital-based case-control study. The POP group consisted of 189 women diagnosed with POP stage III or IV, and the control group consisted of 156 postmenopausal women with POP stage 0 or I. The GSTM1 and GSTT1 null mutations were detected by multiplex PCR, and the GSTP1 Ile105Val polymorphism was genotyped by real-time PCR analysis using a TaqMan assay. ResultsThere was no significant association between the GSTM1 and GSTT1 null mutations and advanced POP (p>0.05). The distribution of the GSTP1 Ile105Val genotypes, however, was significantly different between the POP and control groups (AA/AG/GG rates=74.1%/25.9%/0% vs. 64.1%/32.1%/3.8%, p=0.008), and the G allele frequency was significantly lower in the POP group than in the control group (13.0% vs. 19.9%, p=0.014). Women with the non-AA genotype had a 0.63-fold lower risk of developing advanced POP than women with the AA genotype (95% CI, 0.39–0.99), and women with the G allele had a 0.60-fold lower risk of advanced POP than women with the A allele (95% CI, 0.40–0.90). ConclusionsThe GSTP1 Ile105Val polymorphism is a protective factor against advanced POP.

Pelvic floor muscle training as an adjunct to prolapse surgery: a randomised feasibility study

Introduction and hypothesisThere is evidence that in nonsurgical populations, pelvic floor muscle training (PFMT) and lifestyle advice improves symptoms and stage of pelvic organ prolapse (POP). Some women, however, require surgery, after which de novo symptoms can develop or additional surgery is required due to recurrence. Robust evidence is required as to the benefit of perioperative PFMT in the postsurgery reduction of symptoms and POP recurrence. The aim of this study was to assess the feasibility of and collect pilot data to inform sample size (SS) calculation for a multicentre randomised controlled trial (RCT) of perioperative PFMT following surgical intervention for POP.MethodsFifty-seven participants were recruited and randomised to a treatment group (one pre and six postoperative PFMT sessions) or a control group (usual care). The primary outcome measure was the Pelvic Organ Prolapse Symptom Score (POP-SS) at 12 months; secondary outcome measures included measurement of prolapse, the pelvic floor and questionnaires relating to urinary and bowel incontinence. All outcomes were measured at 0, 6 and 12 months.ResultsInformation on recruitment, retention and appropriateness of outcome measures for a definitive trial was gathered, and data enabled us to undertake an SS calculation. When compared with the control group (n = 29), benefits to the intervention group (n = 28) were observed in terms of fewer prolapse symptoms at 12 months [mean difference 3.94; 95 % confidence interval (CI) 1.35–6.75; t = 3.24, p = 0.006]; however, these results must be viewed with caution due to possible selection bias.ConclusionWith modifications to design identified in this pilot study, a multicentre RCT is feasible.Electronic supplementary materialThe online version of this article (doi:10.1007/s00192-013-2301-x) contains supplementary material, which is available to authorized users.

Can Vaginal Hysterectomy be Left for the Treatment of Advanced Stage of Pelvic Organ Prolapse?

Can Vaginal Hysterectomy be Left for the Treatment of Advanced Stage of Pelvic Organ Prolapse?

Robotic Compared With Laparoscopic Sacrocolpopexy

Laparoscopic and robotic sacrocolpopexy are widely used for pelvic organ prolapse (POP) treatment. Evidence comparing outcomes and costs is lacking. We compared costs and clinically relevant outcomes in women randomized to laparoscopic sacrocolpopexy compared with robotic sacrocolpopexy. Participants with symptomatic stage POP II or greater, including significant apical support loss, were randomized to either laparoscopic or robotic sacrocolpopexy. We compared surgical costs (including costs for robot, initial hospitalization) and rehospitalization within 6 weeks. Secondary outcomes included postoperative pain, POP quantification, symptom severity and quality of life, and adverse events. We randomized 78 women (mean age 59 years): laparoscopic (n=38) and robotic (n=40). The robotic sacrocolpopexy group had higher initial hospital costs ($19,616 compared with $11,573, P<.001) and over 6 weeks, hospital costs remained higher for robotic sacrocolpopexy ($20,898 compared with $12,170, P<.001). When we excluded costs of robot purchase and maintenance, we did not detect a statistical difference in initial day of surgery costs of robotic compared with laparoscopic ($12,586 compared with $11,573; P=.160) or hospital costs over 6 weeks ($13,867 compared with $12,170; P=.060). The robotic group had longer operating room times (202.8 minutes compared with 178.4 minutes, P=.030) and higher pain scores 1 week after surgery (3.5±2.1 compared with 2.6±2.2; P=.044). There were no group differences in symptom bother by Pelvic Floor Distress Inventory, POP stage, or rate of adverse events. Costs of robotic sacrocolpopexy are higher than laparoscopic, whereas short-term outcomes and complications are similar. Primary cost differences resulted from robot maintenance and purchase costs. Clinicaltrials.gov, www.clinicaltrials.gov, NCT01124916. I.

Predictive Factors for Pelvic Organ Prolapse in Iranian Women’s, An Ordinal Logistic Approc

To investigate the predictors factors of Pelvic Organ Prolapse (POP) in Iranian women by using ordinal logistic regression. The role of risk factors of POP was evaluated among 365 patients attending in two public centres in Ilam province, Iran. Exclusion criteria were of single, pregnant and lactate women receiving hormone replacement therapy. Both the unvaried and multi-variate ordinal logistic regression were used to find the predictive factors of POP and computing sensitivity and specificity of models. In multi-variate ordinal logistic regression the variables of Body Mass Index (BMI) Maximum Birth Weight (MBW) and delivery mode were the most important factors for prediction of prolapse stage. The sensitivity and specificity of multi-variate ordinal logistic, as a screening test, were 95.7% and 48.7% respectively. BMI, MBW and delivery mode can use for prediction of POP stage. Stage of prolapse is an ordinal variable, therefore to show relationship between stage of prolapse and other variables ordinal logistic regression is an appropriate model.

Depression among women with obstetric fistula, and pelvic organ prolapse in northwest Ethiopia

BackgroundThe prevalence of depression is not well studied among women with pelvic floor disorders. Hence, this study aimed to determine the prevalence of depression and its associated factors among women with pelvic floor disorders.MethodsA cross-sectional study was conducted among 306 women with one or more of the advanced pelvic floor disorders who attended at the gynaecologic outpatient clinic of Gondar university referral hospital in the six months data collection period. Women who complained of urinary or faecal incontinence or protruding mass per vagina were assessed and staged accordingly. Eligible women i.e. those with advanced pelvic organ prolapse or obstetric fistula were included consecutively. A structured questionnaire was used to obtain socio-demographic data and medical histories for all consenting women. Interviews were done by a female midwife nurse. Depression measures were obtained using the Beck’s Depression Inventory (BDI) tool administered by the midwife nurse after intensive training. Data were entered into a computer using Epi Info version 3. 5.3, and then exported to SPSS version 20 for analysis. Multiple logistic regressions were fitted and Odds ratios with 95% confidence intervals were calculated to identify associated factors.ResultsOf the 306 women interviewed, 269 had advanced pelvic organ prolapse (stages 3 and 4), 37 had obstetric fistula. All four women (100%) with both faecal and urinary incontinence, 97.0% those with urinary incontinence due to obstetric fistula and 67.7% of those with advanced pelvic organ prolapse (stages 3 and 4) had symptoms of depression. Depression was significantly associated with age 50 years or older (P < 0.01), marital status (P < 0.05), history of divorce (p < 0.01), self perception of severe problem (P < 0.05), and having stage 3 pelvic organ prolapse (P < 0.01).ConclusionWomen with advanced pelvic organ prolapse, and obstetric fistula had high prevalence of depressive symptoms. A holistic management approach, including mental health care is recommended for women having such severe forms of pelvic floor disorders.

Factors affecting reflex pelvic floor muscle contraction patterns in women with pelvic floor disorders

To explore factors affecting the presence of two reflex pelvic floor muscle contraction (PFMC) patterns in women with pelvic floor disorders. This was a retrospective analysis of pelvic floor ultrasonography and urodynamic data for 667 consecutive symptomatic women with pelvic floor disorders. We identified on ultrasonography the presence or absence of two reflex PFMC patterns, anorectal lift (ARL) and inward clitoral motion (ICM), preceding or occurring during coughing, and evaluated their associations with possible factors affecting reflex PFMC reactivity, including patient demographics, pelvic organ prolapse stages, ultrasonography findings and urodynamic data. Of the 667 women, 560 (84.0%) clearly demonstrated reflex ARL and 536 (80.4%) demonstrated ICM. There were significant differences in age (P < 0.001), parity (P = 0.033) and menopausal status (P = 0.005) between women with and those without reflex ICM before or during coughing. The multivariable logistic regression model showed that age was the only independent factor associated with presence of reflex ICM (odds ratio, 0.93 (95% CI, 0.88-0.99), P = 0.017). In contrast, no significant differences were noted between women with and without reflex ARL. Increasing age is negatively associated with the presence of reflex ICM during coughing in symptomatic women with pelvic floor disorders.

Standardization of dynamic magnetic resonance imaging measurements of pelvic organ prolapse: can the PICS line help?

Dynamic magnetic resonance imaging (MRI) of the pelvis has been rapidly introduced into urogynecological research and practice in recent years mainly to address the shortcomings of clinical assessment systems in women with pelvic organ prolapse (POP). The primary objective was to better select candidates for surgical intervention and choose the appropriate procedure in order to reduce recurrences by allowing accurate identification and objective measurement of prolapse and simultaneous topographic assessment of the pelvis at rest and straining [1–5]. MRI is particularly indicated in women with multi-compartment POP and in those who had undergone previous repair, as imaging can reveal more extensive prolapse than physical examination alone with detection rates similar to other conventional fluoroscopic and ultrasound methods [1, 3, 4]. Staging of POP using MRI has also been suggested by measuring the perpendicular distance between several reference points and lines in each compartment at rest and after straining [1–5]. The two most commonly used lines are one connecting the inferior aspect of the pubic symphysis to the last coccygeal joint, the pubococcygeal line (PCL), and one extending caudally along the long axis of the symphysis pubis, the midpubic line (MPL). Several MRI staging systems have been published for both of these lines [1, 3, 4]. Despite the widely accepted role of MRI in supplementing clinical evaluation and management of women with POP, this imaging modality has certain limitations. Most importantly, so far, there has been no standardized technique for performing MRI examination of the pelvis. Imaging protocols vary according to patient positioning, filling media, pelvic organ opacification, patient maneuvers (i.e., rest, Kegel, Valsalva, evacuation) and MRI sequences and planes [1–5]. Most of the available imaging systems are unable to demonstrate the full extent of POP because patients are examined in a supine position promoting current efforts to image patients in the sitting and upright position using open-magnet MRI units [1, 3–5]. In fact, sagittal plane images of women with POP that are commonly displayed in the literature as if taken in the upright position had been made in the supine position [6]. A further major problem with MRI studies of the pelvis is the incomplete reproducibility and lack of standardization of the patient effort exerted during straining [3–5]. The anatomical landmarks used for pelvic measurements are easily identified inMRI and this is expected to increase the validity of measurement [5]. The intraand inter-observer reliability of most MRI measurements is, however, rarely described in POP studies [2]. Furthermore, the reference line used for MRI interpretation of POP is not consistent in all studies as this is often based on radiologist experience and referring physician preference [1, 5]. In a recent systematic review, seven different reference lines in relation to a wide variety of reference points have been used in different studies with imprecise definition or interchangeable use of some lines, e.g. “MPL/hymenal line” and “PCL/sacrococcygeal inferior pubic point line” [2]. Although the MPL corresponds anatomically to the level of the hymen on cadaveric dissection, the landmark used for clinical staging of POP, the reliability of MRI using the MPL versus clinical findings in women with POP was lower than that of the PCL in most reports [1, 2]. It is obvious that we lack a proper validation system for interpreting MRI measurements of POP and we urgently need to reach a consensus on a more standardized and scientifically robust MRI protocol for examination of the pelvis. Betschart et al. review this topic further in a seminal Clinical Opinion D. E. E. Rizk Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt

How do delivery mode and parity affect pelvic organ prolapse?

To determine the association between mode of delivery, parity, and pelvic organ prolapse, as assessed by the pelvic organ prolapse quantification system. Cross-sectional study. Tertiary referral center, Turkey. A total of 1964 women with benign gynecological disorders who presented between October 2009 and July 2011. Evaluation using the pelvic organ prolapse quantification system and questionnaire assessing previous obstetrics and medical history. Difference in pelvic organ prolapse stages between nulliparous and multiparous women, impact of parity and mode of delivery. In the study population, 86.4, 7.2 and 6.4% had pelvic organ prolapse of stages 0-I, II, and III-IV, respectively, and 7.9% had significant prolapse beyond the hymen. The mean age, parity, and number of vaginal deliveries were significantly higher in the prolapse than in the non-prolapse group. Vaginal delivery was associated with an odds ratio of 2.92 (95% confidence interval 1.19-7.17) for prolapse when compared with nulliparity. Each vaginal delivery increased the risk of prolapse (odds ratio 1.23; 95% confidence interval 1.12-1.35) after controlling for all confounding factors. Cesarean delivery had no impact on the odds for prolapse. Vaginal delivery was an independent risk factor for prolapse, and additional vaginal deliveries significantly increased the risk. However, cesarean delivery had no effect on the development of prolapse in this material.