Symptomatic Prolapse Research Articles

Comparison between Delayed Absorbable and Permanent Sutures in Laparoscopic Sacral Colpopexy: A Randomized Controlled Trial

Study Objective To demonstrate the non-inferiority of delayed absorbable sutures compared to non-absorbable sutures in laparoscopic sacrocolpopexy (LSC) for correction of pelvic organ prolapse. Design It is a randomized 1:1 non-inferiority surgical clinical trial (NCT03582410). Setting Obstetric and Gynecological Department of “Ospedale Regionale F. Miulli”. Patients or Participants 160 patients, who required surgical treatment for symptomatic prolapse were assessed for eligibility. 6 patients declined to participate and 4 patients did not meet inclusion criteria. 150 patients were enrolled and all completed follow up. Interventions Patients were randomized to receive LSC with delayed absorbable (group A: 75 patients) and non-absorbable sutures (group B: 75 patients) for anterior and posterior mesh fixation to vagina. Primary outcome was the correction of the prolapse at 1, 6 and 12 months after surgery. Intraoperative parameters, intraoperative and postoperative characteristics and long term morbidity were considered as secondary outcomes. Measurements and Main Results Baseline characteristics were comparable between groups. There were no differences in terms of blood loss, operation time, intraoperative complications. No cases of failure and no differences in terms of prolapse correction were observed. There was bowel symptoms gradual reduction in both groups. Rate of de novo urinary incontinence and persistent urinary incontinence after 12 months was similar (respectively 7% in group A vs 5% in group B, p: 1,00 and 11 %in group A vs 5% in group B, p: 0,229). Rate of mesh erosion at 12 months was higher in group B though not statistically significant (4% vs 0%, p:0,24). Conclusion Delayed absorbable sutures are comparable to non-absorbable sutures for mesh fixation in LSC in terms of success of procedure, operative parameters, intraoperative and post-operative characteristics. Other studies are needed to clarify if absorbable sutures can be associated to a decreased rate of mesh erosions.

Extraperitoneal Uterosacral Ligament Hysteropexy: A Novel Treatment for Apical Compartment Prolapse

Study Objective To develop and demonstrate a novel, uterine sparing extraperitoneal uterosacral ligament hysteropexy technique for treatment of mild to moderate apical compartment prolapse. Design Retrospective case series from 2017 to 2019. Setting Academic affiliated hospital. Patients or Participants A total of 15 patients with median pre-operative POP-Q stage 2 apical compartment prolapse desiring uterine preservation, who underwent extraperitoneal uterosacral ligament hysteropexy. Interventions Surgical intervention with extraperitoneal uterosacral ligament hysteropexy. Measurements and Main Results Baseline patient demographics included: mean age of 65 years old, history of diabetes in 3 patients (20%), and history of smoking in 4 patients (26%). The median follow-up was 24 weeks (range of 21 to 100 weeks). The surgical procedure had a mean operative time of 110 minutes with a mean estimated blood loss (EBL) of 101 ml. Concomitant procedure included anterior & posterior repairs in 15 patients (100%) and placement of mid-urethral slings in 4 patients (26%). The objective cure rate (POP-Q apical prolapse stage less than or equal to 1) was 100%. The subjective cure rate (resolution of prolapse symptoms) was 100%. During the follow-up period no patients underwent additional surgeries for recurrent prolapse. The mean loss of total vaginal length compared to baseline was 0.5 cm. One patient had a urinary tract infection within 6 weeks of the procedure (6%). No ureteral obstructions or other complications were reported during this study. Conclusion Short term success and low rates of complications were found following extraperitoneal uterosacral ligament hysteropexy. This procedure could serve as an alternative treatment for apical prolapse in patients desiring uterine preservation.

Three years prospective clinical and radiologic follow-up of laparoscopic sacrocolpoperineopexy.

When Rectocele is part of a complex pelvic organ prolapse, a full repair is recommended. The aim of this study was to evaluate the clinical and radiological results after laparoscopic surgery in patients with symptomatic rectocele and III/IV stage vaginal vault prolapse METHODS: This is a prospective cohort study of women with symptomatic rectoceles and middle compartment prolapse operated on between 2013 and 2015, who underwent a laparoscopic sacrocolpoperineopexy with synthetic Y mesh attached to puborectalis muscles, the anterior and posterior vagina wall and the sacrum. The clinical outcomes measured were symptoms of prolapse, obstructive defecation syndrome and quality of life. Radiological outcomes were distance of the vaginal vault below pubococcigeal line and depth of rectovaginal wall protrusion in dynamic pelvic resonance. 33 patients were included. 32 of them remained asymptomatic after a three years follow-up. Significant differences were shown in the obstructed defecation score and quality of life after 6, 12 and 36months compared to preoperatively. No differences were identified when the postoperative results were compared. Significant differences were shown in preoperative vaginal vault prolapse (3.2cms ± 0.8 SD below the pubococcigeal Line) and rectocele size, compared with 1 and 3years after surgery. There were no significant differences in vaginal vault prolapse when compared after 1 and 3years. When rectocele size after 1 and 3years was compared, significant differences were shown, but only one clinical recurrence (3%) was identified after a mean follow-up of 47months. Laparoscopic sacrocolpoperineopexy in patients with symptomatic rectocele and III/IV vaginal vault prolapse solves the constipation and obstructed defecation with an excellent quality of life and low clinical recurrences. Radiological deterioration, especially in rectocele size, was identified in the mid-term follow-up without clinical significance.

Clinical and cost-effectiveness of vaginal pessary self-management compared to clinic-based care for pelvic organ prolapse: protocol for the TOPSY randomised controlled trial

BackgroundPelvic organ prolapse (or prolapse) is a common condition in women where the pelvic organs (bladder, bowel or womb) descend into the vagina and cause distressing symptoms that adversely affect quality of life. Many women will use a vaginal pessary to treat their prolapse symptoms. Clinic-based care usually consists of having a pessary fitted in a primary or secondary care setting, and returning approximately every 6 months for healthcare professional review and pessary change. However, it is possible that women could remove, clean and re-insert their pessary themselves; this is called self-management. This trial aims to assess if self-management of a vaginal pessary is associated with better quality of life for women with prolapse when compared to clinic-based care.MethodsThis is a multicentre randomised controlled trial in at least 17 UK centres. The intervention group will receive pessary self-management teaching, a self-management information leaflet, a follow-up phone call and access to a local telephone number for clinical support. The control group will receive the clinic-based pessary care which is standard at their centre. Demographic and medical history data will be collected from both groups at baseline. The primary outcome is condition-specific quality of life at 18 months’ post-randomisation. Several secondary outcomes will also be assessed using participant-completed questionnaires. Questionnaires will be administered at baseline, 6, 12 and 18 months’ post-randomisation. An economic evaluation will be carried out alongside the trial to evaluate cost-effectiveness. A process evaluation will run parallel to the trial, the protocol for which is reported in a companion paper.DiscussionThe results of the trial will provide robust evidence of the effectiveness of pessary self-management compared to clinic-based care in terms of improving women’s quality of life, and of its cost-effectiveness.Trial registrationISRCTN Registry ISRCTN62510577. Registered on June 10, 2017.

Colposuspensión latero-abdominal laparoscópica: descripción, ventajas y resultados preliminares

IntroductionThere are currently various fixation or suspension techniques for pelvic organ prolapse (POP) surgery. Laparoscopic colposacropexy is considered the gold standard. We present the surgical steps of the laparoscopic latero-abdominal colposuspension (LACS) technique and the preliminary results obtained. Material and methodsPatients with anterior and/or apical compartment symptomatic POP undergoing LACS are included. The Baden-Walker scale, the Overactive Bladder Questionnaire-Short Form (OAB-q SF), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Patient Global Impression of Improvement (PGI-I) scale were used to assess the degree of prolapse, urinary filling and sexual symptoms and the level of satisfaction before and after surgery, respectively. Conventional laparoscopic material and a polyvinylidene fluoride (PVDF) mesh were used. ResultsEighteen patients were included with a minimum follow-up time of 6months. The mean surgical time was 70.3±23.8min. Anatomic correction of prolapse was seen in all cases. Only one recurrence was detected. High levels of patient satisfaction were achieved. ConclusionLACS allowed the anatomical reconstruction of the pelvic floor and proved to be a minimally invasive, fast, effective, safe and reproducible technique. More series are needed to evaluate its role against laparoscopic colposacropexy.

Coexistent faecal incontinence and constipation: A cross-sectional study of 4027 adults undergoing specialist assessment.

BackgroundIn contrast to paediatric and geriatric populations, faecal incontinence and constipation in adults are generally considered separate entities. This may be incorrect.MethodsCross-sectional study of consecutive patients (18–80 years) referred to a tertiary unit (2004–2016) for investigation of refractory faecal incontinence and/or constipation and meeting Rome IV core criteria (applied post-hoc) for self-reported symptoms. We sought to determine how frequently both diagnoses coexisted, how frequently coexistent diagnoses were recognised by the referring clinician and to evaluate differences in clinical characteristics between patients with single or both diagnoses.FindingsStudy sample consisted of 4,027 patients (3,370 females [83·7%]). According to Rome IV criteria, 807 (20·0%) patients self-reported faecal incontinence in isolation, 1,569 (39·0%) patients had functional constipation in isolation, and 1,651 (41·0%) met criteria for both diagnoses (coexistent symptoms). In contrast, only 331 (8·2%) patients were referred for coexistent symptoms. Of the 1,651 patients with self-reported coexistent symptoms, only 225 (13·6%) were recognised by the referrer i.e. 86·4% were missed. Coexistent symptoms were most often missed in patients referred for faecal incontinence in isolation. In this group of 1,640 patients, 765 (46·7%) had concomitant symptoms of functional constipation. Opioid usage, comorbidities, childhood bowel problems, mixed incontinence symptoms, prolapse symptoms and structural abnormalities on defaecography were associated with reclassification.InterpretationOver 40% of adults referred for anorectal physiological investigation had coexistent diagnoses of faecal incontinence and functional constipation, based on validated criteria. This overlap is overlooked by referrers, poorly documented in current literature, and may impact management.

An innovative device in the management of female urodynamic stress incontinence: a perception survey.

Urinary incontinence significantly affects daily life of suffering women. Minimally invasive solutions to cope with urine leakage would be of great interest. A survey to investigate efficacy and compliance of an innovative intravaginal device (Diveen®) to reduce the risk of urine leakage was performed in 5 Urogynecological Centers across Italy. Women with urodynamic diagnosis of stress incontinence, included mixed conditions, underwent the survey. The device was effective (60%) independently from severity of Incontinence or the presence of concomitant detrusor overactivity (mixed forms) with a positive impact on quality of life in more than half of the women. Also compliance with the device was satisfactory (up to 73%). Clinically symptomatic prolapse and age >65 years are the only limiting factors in terms of efficacy and compliance, while the menopausal status would not seem to affect these aspects. Despite global satisfactory outcomes, 46% of the surveyed women declare their propensity to use the device. This data deserves further investigation.

Laparoscopic cervicopexy for correction of apical genital prolapse in 10 steps: a pilot study.

Surgical repair of pelvic organ prolapse is one of the most frequent gynecological procedures, and its frequency is expected to increase as the population is gradually aging. Mesh use in urogynecological surgery should be limited because of important and life-treating complications. Sacral mesh-less and lateral procedures have been described as safe and effective to treat apical compartment prolapse. In this video, we describe a new laparoscopic mesh-less cervicopexy in women with symptomatic uterovaginal prolapse who did not desire uterine preservation. Eleven women with symptomatic uterovaginal prolapse [stage 2 or higher according to the Pelvic Organ Prolapse Quantitative (POP-Q) classification system] underwent laparoscopic mesh-less cervicopexy to the sacrum and transverse fascia between May 2018 and June 2019. We performed application of the right uterosacral ligament starting from the sacrum and two semicontinous sutures including the transverse fascia, round ligament, prevescical peritoneum, pubocervical fascia and cervix that were subsequently knotted. At 6-month follow-up, the objective success rate for apical prolapse (POP-Q score C > -1) was 90.9% (10/11 women). Only one woman presented stage 3 apical prolapse recurrence with vaginal buldge. Laparoscopic mesh-less cervicopexy for uterovaginal prolapse seems to be a feasible surgical technique at 6-month follow-up.

Do women runners report more pelvic floor symptoms than women in CrossFit®? A cross-sectional survey.

Women who perform high-impact activities might be at greater risk of pelvic floor dysfunction (PFD) than those participating in low-impact exercise; however, little is known about whether PFD is more common in one type of high-impact activity than another. The aim of this study was to compare the prevalence of PFD symptoms in women who engage in high-impact activity compared with CrossFit®-brand training (CF). An online survey collected data from 1,379 women (521 runners, 858 CF) on exercise participation, parity, and PFD symptoms, via the Pelvic Floor Distress Inventory (PFDI-20). Specific questions from each PFDI-20 subscale further investigated symptoms of pelvic organ prolapse (POP), anal incontinence (AI), as well as stress (SUI) and urgency (UUI) urinary incontinence. Symptoms of POP and AI were significantly higher in runners (POP 12.7%, AI 34.0%) than in CF (POP 7.8%, p= 0.003; AI 27.7%, p= 0.014). There was no significant difference in SUI symptoms between groups (37.0% vs 41.0% respectively, p= 0.141). Vaginally parous runners reported significantly more symptoms of POP (19.0% vs 12.2%, p= 0.023), AI (39.3% vs 27.2%, p= 0.001), and UUI (36.3% vs 29.0%, p= 0.037) than CF. Women, particularly parous women, who participate in running, have a higher prevalence of POP and AI symptoms than women who participate in CF. This suggests that CrossFit®-brand training might not be more detrimental to PFD symptoms than other high-impact activity, such as running. This study does not conclude a pelvic floor health benefit of one exercise over another, but highlights that exercise options can be provided to women.

A service evaluation to determine where and who delivers pessary care in the UK.

Pessaries offer effective conservative management for symptoms of pelvic organ prolapse and are frequently used in the UK. Previous publications have highlighted a lack of evidence-based pessary guidelines. There is also a dearth of evidence regarding who UK pessary practitioners are and the training received. A Freedom of Information request was sent to 167 healthcare organisations in the UK. Requested information included the number of pessaries inserted or changed, the grade and profession of pessary practitioners and training requirements at the organisation. Responses were received from 128 organisations. One hundred and ten had provided information for practitioners managing pessaries. At 66% (72) of organisations, pessary care was provided by both doctors and nurses of varying grades. At 23% of organisations either solely doctors or solely nurses provided pessary care. At the remaining 9% there was a multidisciplinary approach to pessary care. At 3 hospitals, unregistered healthcare professionals provided pessary care. At the majority of organisations, respondents undertook supervised practise to gain skills in pessary management. Additional methods of training cited were learning through observation or achieving set competencies. Twenty-six percent received didactic training. At 21% of organisations there were no training requirements. At most organisations, there was a multidisciplinary approach to pessary care. It is questionable whether unregistered healthcare professionals should be delegated responsibility for pessary care. A standardised approach to pessary practitioner training is advocated to ensure that women receive safe, evidence-based pessary care. The UK Clinical Guidance Group for the Use of Pessaries in Vaginal Prolapse is currently developing national evidence-based guidelines to support pessary practitioners in their practice, including training requirements.

Restricted Convalescence Following Urogynecologic Procedures: 1-Year Outcomes From a Randomized Controlled Study.

To assess the relationship between postoperative activity recommendations and satisfaction and anatomic and functional outcomes 1 year after surgery for symptomatic prolapse. This is a planned secondary analysis reporting 1-year functional and anatomic outcomes of a multicenter, randomized, double-masked clinical trial "ReCOUP." In the original trial, women undergoing surgery for prolapse were randomized to liberal (no limitations on physical activity) or restricted (heavy lifting and high-impact activity prohibited) postoperative activity recommendations for 3 months after surgery. At 1 year, our primary outcome was satisfaction, assessed using a 5-point Likert scale answer to the question, "How satisfied are you with the result of your prolapse surgery?" Anatomic surgical failure was met if women had prolapse beyond the hymen, apical descent greater than one third the vaginal length, OR retreatment for prolapse. Of the 95 women (n = 45 liberal, n = 50 restricted) who were randomized and completed primary 3-month outcomes, 83 (87%) completed a functional assessment, and 77 (81%) completed both functional and anatomic assessment at 1 year. Satisfaction with surgery remained high (91.5%) with no differences between groups (86.8% vs 95.6% P = 0.155) as did anatomic and functional outcomes. There were 7.8% women who met criteria for anatomic surgical failure with no difference between the restricted (7.0%) and liberal group (8.8%). Three women (2 in the restricted group, 1 in the liberal group) with recurrent prolapse and underwent surgery. There were no significant differences in anatomic and functional outcomes at 12 months after surgery in women who resume postoperative activity liberally and those who restrict postoperative activity.

Pelvic Organ Prolapse Severity and Genital Hiatus Size With Long-Term Pessary Use.

To evaluate the association between pessary use more than 1 year and change in prolapse severity. This is a secondary analysis of a previously published randomized controlled trial of women undergoing office management of pessaries for management of symptomatic pelvic organ prolapse and incontinence. Primary outcome was change in pelvic organ prolapse quantification measurement genital hiatus (GH). Secondary outcomes included change in prolapse stage, type of pessary, size of pessary, number of pessary changes, and duration of use. Baseline data were collected from the earliest documented examination within the hospital record before pessary placement and compared with their final study visit. Demographics were analyzed using descriptive statistics. Student t test and Mann-Whitney tests were used for categorical comparisons. Pearson and Spearman correlation coefficients were used to evaluate change over time. The cohort was 132 predominantly non-Hispanic White (75%) women with symptomatic prolapse >stage 2 (70.5%). All were postmenopausal. Median duration of pessary use was 39.5 months (interquartile range, 17-64.5 months). Genital hiatus (P = 0.014) and prolapse stage (P = 0.001) decreased as duration of pessary use increased. Those with baseline stages ≥3 had a significant decrease in GH as duration of pessary use increased compared with stages <3 (-0.5 cm vs 0 cm, P < 0.001). There was no difference in change in GH when comparing women with baseline GH less than 3 to 3 cm or greater. Pessary use by women with pelvic organ prolapse causes a change in vaginal anatomy over time as seen by decreasing stage and point GH.

Outcomes of Single Incision Anchored Anterior Vaginal Mesh Repair for Recurrent Vaginal Prolapse

Objective: To report the safety and efficacy of single incision anchored anterior vaginal mesh repair for women with recurrent anterior vaginal prolapse.Methods: Retrospective study of women with recurrent anterior vaginal prolapse, Stage 2 or beyond, who underwent single incision anchored vaginal mesh repair with Anterior Elevate (American Medical Systems, Minnetonka, USA) between June 2012 and October 2016. Pre-operatively, the Prolapse Quality-of-Life questionnaire (P-QOL) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 (PISQ-12) were completed. Post-operatively, women completed the P-QOL, PISQ-12 and the global impression of improvement questionnaire (PGI-I). Preoperative POP-Q and post operative POP-Q examination at up to 24 months follow up were recorded. At average follow up of 36 months, participants were interviewed via telephone using questions from the P-QOL, PISQ and PGI-I.Results: 45 women had single incision anterior vaginal mesh kit repair for recurrent prolapse. Postoperatively, 85% of women reported cure of their prolapse symptoms. At 24 months, 80.0% had POP-Q stage 0 or 1 in the anterior compartment, and 93.8% achieved anatomical cure of apical prolapse (point C above 0). During structured telephone interview at mean follow up of 36 months, on PGI-I, 70% reported feeling ‘much better’ or ‘very much better’.Conclusion: Vaginal surgery using single incision lightweight mesh kits can be an effective approach for women with recurrent anterior vaginal prolapse, resulting in subjective and objective cure rates of over 80% with reasonable safety profile up to 60 months postoperatively.

Validation of the Chinese version of the Pelvic Organ Prolapse Symptom Score (POP-SS).

The objective of the present study was to translate the Pelvic Organ Prolapse Symptom Score (POP-SS) into Chinese and validate it in a population of Chinese women. The POP-SS questionnaire was translated into simplified Chinese language following an intercultural adaptation procedure. One hundred forty-six patients who met the inclusion criteria were recruited. Among the enrolled patients, 63 underwent surgery for POP and 50 underwent pessary management. They completed the questionnaires at baseline (T1), 1 to 2 weeks later (T2), and 3 months after intervention (T3). Evaluation for psychometric properties was conducted following with the COnsensus-based Standards for the selection of health Measurement INstruments checklist, including internal consistency, test-retest reliability, measurement error, content validity, criterion validity, construct validity, responsiveness, and interpretability. The POP-SS was successfully translated into a Chinese version and achieved good content validity. Internal consistency (Cronbach's alpha = 0.796) was good, and test-retest reliability was excellent (intraclass correlation coefficients = 0.98; P < 0.001). The construct validity was verified by factor analysis and consistent with the theoretical structure of the original questionnaire. The POP-SS score was also significantly correlated with Pelvic Floor Distress Inventory-20 (Spearman's correlation coefficient = 0.89, P < 0.001). The confirmatory factor analysis identified two factors: physical symptoms and evacuation symptoms. The mean changes among the participants in very much better (9.80 ± 5.36) and much better (5.67 ± 2.99) groups were larger than those among the participants in the no change group (0.43 ± 2.07). The effect size responsiveness parameter in the much better group (>0.80) was larger than that in the no change group (<0.20). The values of the minimal important change for surgery and pessary groups were both larger than the smallest detectable change, indicating sufficient responsiveness. The Chinese version of POP-SS is a reliable and valid instrument and has good sensitivity to change in the population studied.

Urogynaecological Symptoms among Oncological Survivors and Impact of Oncological Treatment on Pelvic Floor Disorders and Lower Urinary Tract Symptoms. A Six-Month Follow-Up Study.

It has been widely underlined that both gynaecological malignancies and urogynaecological disorders are often associated with high stress and have a negative impact on the quality of life and psychological well-being of women affected. Knowledge of the pelvic anatomy is crucial in recommending and carrying out the least harmful although successful treatment. Subsequent chemoradiation may also induce or exaggerate troublesome symptoms. The aim of the study was to establish the frequency of urogynaecological symptoms (stress urinary incontinence, urgency, pelvic organ prolapse) and to assess the impact of surgical treatment and additional oncological therapy: pelvic radiation, chemoradiation, chemotherapy, on the prevalence of pelvic floor dysfunctions (PFD) and lower urinary tract symptoms (LUTS) in patients suffering from gynecological malignancies. The study group consisted of 160 women, diagnosed with gynaecological malignancy, who underwent surgical treatment and additional adjuvant treatment as necessary. To establish the QoL and prevalence of PFD Urinary Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire 7 (II-Q7), King’s Health Questionnaire (KHQ) and the SF-36 Questionnaire were used. Herein, 69 patients reported urinary incontinence (UI) and 67 reported symptoms of pelvic organ prolapse (POP). After the six months follow-up UI was found in 78 patients, 25 patients showed de novo symptoms, 65 patients reported POP and 10 patients demonstrated de novo POP. Our data show that urogynaecological symptoms are not correlated with the type of malignancy, but with the extensiveness of surgery.

The use of 3D ultrasound in comparing surgical techniques for posterior wall prolapse repair: a pilot randomised controlled trial

The most appropriate method for repairing posterior vaginal wall prolapse is still debatable. Women with symptomatic prolapse scheduled to undergo surgical repair in the posterior compartment were randomised to standard posterior colporrhaphy (SPC) or fascial and vaginal epithelial plication (FEP). Participants were assessed with the Prolapse Quality of Life (P-QOL) questionnaire, pelvic organ prolapse quantification (POP-Q) examination and three-dimensional ultrasound (3D US) prior to surgery and 6 months postoperatively. The research hypothesis is that 3D US of the pelvic floor is a reliable tool in comparing the anatomical outcomes of the two different surgical techniques. Differences in anatomical outcomes, assessed clinically and by ultrasonographic evaluation, were compared between the two groups using the Independent Mann–Whitney U-test and the Wilcoxon signed-rank sum test. Twenty-two women were included in the analysis. Six months postoperatively, women in the FEP arm had better anatomical outcomes compared to those who had undergone SPC (p = .02). Repeatability of the ultrasound technique was confirmed, showing moderate to very good agreement in all parameters and the 3D US evaluation was corroborated with the clinical examination, showing a greater reduction in the urogenital size in the FEP group. Impact statement What is already known on this subject? The low cost and universal availability of the ultrasound (US) makes it the most commonly used diagnostic modality. The ability to see beyond surface anatomy is important and useful in the assessment of the posterior vaginal wall prolapse and the obstructed defaecation, where this method may replace the defaecation proctography (Dietz 2019). Recent advances in pelvic floor ultrasonography (3D US) have achieved repeatability in the measurement of the levator hiatal (LH) dimensions, introducing a valid and readily available tool for researchers and clinicians (Dietz et al. 2005). Ultrasound may distinguish a true rectocele due to the weakening of the rectovaginal fascia from an enterocele, a rectal intussusception, or just a deficient perineum (Guzman Rojas et al. 2016). What do the results of this study add? Our study demonstrates that 3D translabial pelvic floor ultrasound is a useful and reliable tool in assessing the anatomical outcome of prolapse surgery. What are the implications of these findings for clinical practice and/or further research? Our study demonstrates that 3D translabial ultrasound of the pelvic floor is a useful and reproducible method in evaluating the anatomical outcomes of surgical repair for posterior wall prolapse. Genital hiatus (GH) and levator hiatus (LH) dimensions measured by ultrasound can be used as surrogate anatomical markers in comparing the efficacy of different surgical techniques.

Pessary evaluation for genital prolapse treatment: From acceptance to successful fitting.

To determine the percentage of women with symptomatic pelvic organ prolapse who opted for pessary and had a successful pessary fitting trial; to identify the most commonly used size of pessary for stage of prolapse; and to identify risk factors associated with unsuccessful fitting. We conducted a prospective cohort study of women with symptoms of genital prolapse referred to a public hospital tertiary care clinic (2013-2019). We used ring and ring with support pessaries for fittings. We collected patient demographics, pelvic organ prolapse quantification, size of pessary used and evaluated factors associated with pessary fittings. We defined unsuccessful fit as failure to continue pessary use at 4 weeks post fitting trial. We used Mann-Whitney and χ2 tests to compare variables between groups of successfully and unsuccessfully fitted. Using logistic regression, we built a prediction model for unsuccessful fit. All 170 women with symptomatic prolapse referred to our clinic accepted to undergo a pessary fitting. More than 70% (n = 124/72.9%) were successfully at 4 weeks. We used an average of 1.7 pessaries (range: 1-6) per patient to identify the best-fitting pessary and #2, 5, 3, 7, and 4 were the sizes commonly used (78.2%). Women with body mass index ≥30 kg/m2 (odds ratio [OR]: 4.74; 95% confidence interval [CI], 1.98-11.32; P < .001), total vaginal length <7.5 cm (OR: 3.78; 95% CI, 1.98-11.32; P < .001), and sexually active women (OR: 2.26; 95% CI, 1.04-4.91; P = .035) were associated with increased unsuccessful fitting. The vaginal pessary proved to be an excellent choice, with high acceptance and successful fitting rates.

EFFECT OF PERINEAL REPAIR AND MUSHAKADI TAILA MATRABASTI IN MANAGEMENT OF RECTAL PROLAPSE (GUDABHARMSA): A CASE STUDY

Rectal prolapse can present in a variety of forms and is associated with a range of symptoms including pain, incomplete evacuation, bloody and/or mucous rectal discharge, and fecal incontinence or constipa-tion. Complete external rectal prolapse is characterized by a circumferential, full-thickness protrusion of the rectum through the anus, which may be intermittent or may be incarcerated and poses a risk of strangu-lation. There are multiple surgical options to treat rectal prolapse, and thus care should be taken to under-stand each patient’s symptoms, bowel habits, anatomy, and pre-operative expectations. We propose an al-gorithm based on available outcomes data in the literature, an understanding of ano-rectal physiology, and expert opinion that can serve as a guide to determining the rectal prolapse operation that will achieve the best possible postoperative outcomes for individual patients. Mushakadi Taila Matrabasti will be given in Sushrut Samhita as a treatment1 with perineal repair. So, it is really needed to find a safe, easier, less com-plicating, cost effective and fruitful approach for the management of disease through Ayurveda. A 62year old male patient came to the hospital with chief complaints of protrusion of mass from the anus with mu-cous discharge, constipation since last 5 years. He was diagnosed as complete rectal prolapse. Considering the signs and symptoms of rectal prolapse, the treatment of rectal prolapsed was planned with perineal re-pair and Mushakadi Taila Matarabasti as per mentioned in the treatment of Gudabhransha by Aacharya Sushruta.

Does Vaginal Parity Alter the Association Between Symptoms and Signs of Pelvic Organ Prolapse?

This study aimed to investigate whether the number of vaginal births a woman has alters the association between symptoms and signs of pelvic organ prolapse. In this retrospective study, we investigated data on 1748 women seen between April 2012 and January 2016. To elucidate whether the number of vaginal births is a confounder of this relationship, we used receiver operating characteristic statistics to investigate the association between symptoms and signs of prolapse in women of different vaginal parity. A higher number of vaginal births was associated with a higher likelihood of symptoms of prolapse for any given degree of prolapse. Multivariate modeling, however, showed this confounding effect to be due to higher vaginal parity in older women (P < .001). Receiver operating characteristic curves obtained for the association between symptoms and signs of prolapse were near identical regardless of whether vaginal parity was included in the modeling. This was true for both clinical and imaging assessments of prolapse. Although vaginal childbirth is associated with symptoms of prolapse, the number of vaginal births does not alter the relationship between symptoms and signs of prolapse among individuals presenting to a tertiary care center for evaluation. Previously published limits for "normal" pelvic organ mobility can be used irrespective of vaginal parity.

Change in levator ani muscle stiffness and active force during pregnancy and post-partum.

It is assumed changes occur to the biomechanics and viscoelastic response of the levator ani muscle during pregnancy; however, there is limited evidence of this. This study used instrumentation and clinical measures to determine the stiffness and active force capacity of levator ani muscle during pregnancy and post-partum, investigated any associations with delivery outcomes, and explored the biomechanical properties associated with symptoms of pelvic floor dysfunction. This was a prospective observational study, with nulliparous women with a singleton low-risk pregnancy. Data were collected at two stages during pregnancy and post-partum. Measurements included the Australian Pelvic Floor Questionnaire, palpation of active force, and elastometry measurements. Post-partum, 3D/4D ultrasound measurements were included. Repeated measures ANOVAs, pairwise comparisons, Pearson correlation coefficients, and Student's t-tests were used as appropriate. Fifty-nine women took part in the study. Active force was significantly different over the pregnancy and post-partum, measured with instrumentation (p = 0.002) and palpation (p = 0.006 right, p = 0.029 left). There was no significant change in muscle stiffness during pregnancy. Post-partum muscle stiffness was significantly different between women who gave birth vaginally vs. caesarean section (p = 0.002). Post-partum there were differences in levator hiatal area, symptoms of bladder dysfunction, prolapse symptoms, and sexual dysfunction symptoms. Active force of the levator ani muscle was significantly reduced during pregnancy and in the post-partum period, while muscle stiffness reduced only in those who had vaginal deliveries.