Pelvic organ prolapse symptoms in relation to POPQ, ordinal stages and ultrasound prolapse assessment

Adequate staging of pelvic organ prolapse is important in clinical practice and research. The ability of the POPQ, ordinal stages and ultrasound prolapse assessment were evaluated for their ability to discriminate between women with and without prolapse symptoms. The leading edge of the predominant compartment in the three assessment systems was used for the calculation of receiver operating characteristics curves. Two hundred and sixty five (265) consecutive women were evaluated. The area under the receiver operating characteristics curve for the three staging systems ranged from 0.715 to 0.783. POPQ staging and ordinal staging performed equally well in the prediction of prolapse symptoms (p = 0.780), and both performed better as compared with ultrasound prolapse assessment (p = 0.048 and p = 0.015, respectively). Prolapse staging can equally be performed by the POPQ and ordinal stages systems as far as the discrimination between women with and without prolapse symptoms is concerned. The ultrasound prolapse assessment does not perform better as compared with these two systems

AI is a viable alternative to high throughput screening: a 318-target study

: High throughput screening (HTS) is routinely used to identify bioactive small molecules. This requires physical compounds, which limits coverage of accessible chemical space. Computational approaches combined with vast on-demand chemical libraries can access far greater chemical space, provided that the predictive accuracy is sufficient to identify useful molecules. Through the largest and most diverse virtual HTS campaign reported to date, comprising 318 individual projects, we demonstrate that our AtomNet® convolutional neural network successfully finds novel hits across every major therapeutic area and protein class. We address historical limitations of computational screening by demonstrating success for target proteins without known binders, high-quality X-ray crystal structures, or manual cherry-picking of compounds. We show that the molecules selected by the AtomNet® model are novel drug-like scaffolds rather than minor modifications to known bioactive compounds. Our empirical results suggest that computational methods can substantially replace HTS as the first step of small-molecule drug discovery

The mesh debate : transvaginal anterior anchored mesh should not be abandoned

Einstein once said, ‘In the middle of difficulty, lies opportunity’. However, in this current climate when the use of synthetic transvaginal mesh in pelvic organ prolapse (POP) surgery is associated with increasing negative publicity, there is limited opportunity for progress in this field. In fact the authors consider what happened over the last few years a retrograde development. The blanket decision to suspend all mesh use in pelvic floor reconstructive surgery in Scotland in 2014, including synthetic suburethral slings which have a proven success record reaching back about 20 years, is an obvious example. The recent removal from the market of transobturator meshes including the Perigee™ (American Medical Systems (AMS), Minnetonka, MN, USA) and Anterior Prolift™ (Ethicon, Somerville, NJ, USA) is another example of a retrograde development. While these were largely commercial decisions, it is inevitable that clinicians are now forced to revert back to procedures that have been shown to be less effective. In our opinion the discussion surrounding the use of transvaginal mesh has been dominated by emotion rather than science

Comment on Chaudhry et al. : descending perineum syndrome : a review of the presentation, diagnosis, and management

Letter to the Editor

Vaginal birth and pelvic floor trauma

Purpose of Review: Over the last two to three decades, a growing body of research has shown that vaginal childbirth is more traumatic to mothers than generally assumed. Apart from obstetric anal sphincter tears which have been extensively studied, trauma to the levator ani muscle is a form of maternal injury that is less well recognised and often undiagnosed. In the context of an increasing push towards vaginal birth, this article will review the recent literature to better inform health care providers regarding the significance of pelvic floor trauma. Recent Findings: Imaging studies have shown that levator avulsion, where the puborectalis muscle has detached from the os pubis, occurs in up to 1/3 of vaginally primiparous women, depending on demographic factors and obstetric management. Forceps is a well-established risk factor for levator avulsion with an odds ratio of 4–5 compared to vacuum, which does not seem to convey additional risk over unassisted vaginal birth. Levator injuries are significantly associated with pelvic organ prolapse and treatment failure. Such trauma can also lead to significant psychological morbidity, up to and including post-traumatic stress disorder. Antenatal prediction does not appear feasible. Modification of obstetric practice by abandoning forceps would significantly reduce pelvic floor trauma and the future need for prolapse surgery. Summary: Vaginal childbirth is more traumatic than commonly assumed. Levator trauma is associated with significant physical and psychological morbidity. Perinatal health care providers need to understand and recognise the significance of maternal birth trauma and its potential impact on women’s health

Ultrasound imaging of slings and meshes in urogynecology

Imaging is used increasingly in urogynecology. One of the main applications is in the assessment of synthetic implants. Ultrasound is particularly useful for this purpose as most such implants appear highly echogenic on ultrasound but are not visible using other imaging techniques. The worldwide success of synthetic mid-urethral slings, introduced in the late 90s, led to the subsequent introduction of transvaginal mesh in 2003–2004. Widespread use of synthetic implants for both urinary incontinence and prolapse has caused a rise in implant-related complications and increasing negative publicity and litigation, with many products removed from the market. It is not surprising that there is increasing demand for the assessment and evaluation of sling and mesh implants using imaging. This review article discusses the role of translabial/transperineal ultrasound in the evaluation of synthetic implants used in the treatment of urinary incontinence and pelvic organ prolapse. The discussion focuses on those applications of the technique that are useful for surgeons dealing with patients after mesh and/or sling placement

Comment on Vergeldt et al. : Risk factors for pelvic organ prolapse and its recurrence : a sysematic review

Letter to the Edito

Imaging of slings and meshes

The popularity of imaging in pelvic floor medicine continues to increase. Among the various modalities, ultrasound is superior as it is cheap, safe, easily accesible and simple, resulting in high patient compliance. It is the only technique that allows imaging of modern wide-weave polypropylene sling or mesh implants, and imaging of such implants is commonly required due to the popularity of surgical techniques that involve the placement of slings and meshes. This review article will discuss the role of translabial ultrasound in the evaluation of synthetic implants used in the treatment of urinary incontinence and pelvic organ prolapse

Assessment of pelvic organ prolapse : a review

Female Pelvic organ prolapse (FPOP) is a highly prevalent condition. Its incidence is likely to increase further because of aging populations. There is a need to understand treatment and prevention better, and proper diagnosis is the first step towards these ends. Most importantly, we need to define what is ‘normal’ and ‘abnormal’. In this review article we will focus on the clinical and ultrasound assessment of FPOP. Current data suggest pelvic floor injury is important in the pathogenesis of FPOP and as a risk factor for prolapse recurrence after surgery. It has become evident that pelvic floor assessment should be included in the management of women with FPOP. We will discuss the limits of normality for pelvic organ descent, both on translabial/ transperineal ultrasound and on clinical examination, and place special emphasis on measures to avoid false negative findings on FPOP assessment

What is abnormal uterine descent on translabial ultrasound?

Introduction and hypothesis: Ultrasound is increasingly used in evaluating women with pelvic floor dysfunction, including quantification of pelvic organ prolapse (POP). The aim of this study was to define the optimal cutoff for uterine descent on translabial ultrasound (TLUS) to predict symptoms of prolapse. Methods: This was a retrospective study of patients seen for lower urinary tract symptoms and/or POP at a tertiary urogynecological center. All patients underwent a standardized interview, 4D TLUS and the International Continence Society Pelvic Organ Prolapse Quantification system (ICS POP-Q) assessment. Pelvic organ descent on US was measured relative to the posteroinferior margin of the symphysis pubis (SP) on maximum Valsalva. Receiver operator characteristic (ROC) statistics was used to determine the optimal cutoff. Results: We assessed 538 data sets. Mean patient age was 53 years (range 18–88). Prolapse symptoms were reported by 263 (49%). Clinically significant POP, i.e., ICS POP-Q stage ≥2 was found in 74.5%. This comprised a cystocele in 322, uterine prolapse in 63, enterocele in ten, and rectocele in 280 women. On TLUS, mean uterine position on Valsalva was 14.3 mm above the SP. Prolapse symptoms were strongly associated with uterine descent (20.7 mm vs 7.6 mm, P < 0.001). Using ROC statistics with and without excluding women with a dominant prolapse in other compartments, +15 mm was found to be the optimal cutoff for predicting symptoms of prolapse, with areas under the curve of 0.68 and 0.74, respectively. Conclusions: An optimal cutoff to predict prolapse symptoms due to uterine descent is a cervix descending to 15 mm above the symphysis pubis on maximum Valsalva