Pelvic floor dysfunction and quality of life in women

This thesis started with testing the psychometric qualities of the Dutch version of the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). Our analysis of the UDI showed that it consists of five domains that are clinically sound and reliable. Factor analysis of the IIQ showed that, in addition to the original four domains, a fifth factor with four items about embarrassment was extracted. Since women with urinary incontinence often report that they are embarrassed by their incontinence, the inclusion of such a domain in a disease-specific Quality of Life (QoL) questionnaire on urogenital symptoms is essential. With the UDI we found that one out of four women reported symptoms of overactive bladder and that these symptoms had the same negative consequences on QoL as urge incontinence. The prevalence of stress incontinence was as high as 40% but this symptom did not seem to bother women. Besides urinary symptoms we studied the prevalence of flatus and faecal incontinence in a community-based cross-sectional cohort study. We aimed at identifying whether childbirth is a risk factor for flatus and faecal incontinence as is commonly stated in literature. Our results, the first in its kind, show that there is no evidence for a general causal relationship between childbirth and faecal incontinence. Another common life event in women is a hysterectomy. We studied the consequences of hysterectomy on urinary continence. We compared the prevalence and severity of stress- and urge urinary incontinence in women scheduled for hysterectomy with women from a random community sample who were not scheduled for hysterectomy . We did not demonstrate a difference in prevalence between these two groups. However, if urinary incontinence is present, women scheduled for hysterectomy are significantly more bothered by it as compared to women from the community sample. We also studied the long-term consequences of hysterectomy on urge and stress urinary incontinence and found that hysterectomy increases the risk for urge incontinence but not for stress incontinence. Especially since urge incontinence negatively affects QoL, we recommend that women should be informed about this long-term consequence of hysterectomy. Finally we studied the effect of different coping strategies on QoL in women with symptoms of pelvic floor dysfunction. We showed that, at the same level of symptom severity, women who more frequently used emotion-oriented and passive coping strategies reported a significantly worse QoL as compared to women who applied more problemoriented, active coping strategies. These coping strategies were also of importance in relation to help-seeking behaviour in women with symptoms of pelvic floor dysfunction. First, we analysed differences between clinical cases and community cases with mild symptoms of pelvic floor dysfunction and found that clinical cases expressed more passive coping strategies as compared to community cases. Secondly, we analysed differences between clinical cases and community cases with severe symptoms of pelvic floor dysfunction and found that clinical cases expressed more problem-oriented, active coping strategies as compared to community cases. In addition, we found that lower educated women significantly more often presented themselves with mild symptoms at our clinic as compared to higher educated women. This implicates that these women have an increased risk of undergoing diagnostic and therapeutic procedures at low symptom severity levels

Buttock pain after sacrospinous hysteropexy: reply to Wallner

We greatly appreciate the comment by Dr. Wallner [1] on the new insight into the positioning of the pudendal and levator ani nerves in relation to the complaint of buttock pain after sacrospinous hysteropexy [2]

A nationwide survey concerning practices in pessary use for pelvic organ prolapse in The Netherlands: identifying needs for further research

Introduction and hypothesis: To identify practice variation in management of patients with a vaginal pessary for pelvic organ prolapse (POP). Methods: A nationwide survey was sent to all Dutch gynecologists with a special interest in urogynecology. Results: The response rate was 59 %. Of the respondents, 13 % had a written protocol for pessary treatment in their department. Pessary treatment was proposed by 69 % of respondents as a treatment option. Counseling about side effects varied. All respondents provided information concerning the possibility of serious vaginal discharge. Concerning this side effect, 15 % of the respondents stated that it occurs in 5 – 20 % of patients, 27 % that it occurs in 20 – 40 % of patients, and 57 % that it occurs in more than 40 % of patients. Another item concerned counseling for the likelihood of vaginal blood loss. All respondents provided information concerning the possibility of vaginal blood loss. Concerning this side effect, 53 % of the respondents stated that it occurs in 5 – 20 % of patients, 33 % that it occurs in 20 – 40 %, and 14 % that it occurs in more than 40 % of patients. Follow-up after initial placement was done by 69 % of the respondents at 2 – 6 weeks, by 2 % at 8 weeks, and by 29 % at 12 weeks or more. Most (98 %) of the respondents extended the interval between visits when the patient had no complaints, and 96 % of the respondents reported that they routinely instruct patients about self-management. Conclusions: Pessaries are suggested as a treatment option by a majority of gynecologists, but practice varies widely. We consider that the variation in practice is due to a lack of available protocols and lack of evidence

Tunneling Conductance and Coulomb Blockade Peak Splitting of Two Quantum Dots Connected by a Quantum Point Contact

By using bosonization method and unitary transformation, we give a general relation between the dimensionless tunneling conductance and the fractional Coulomb blockade conductance peak splitting which is valid both for weak and strong transmission between two quantum dots, and show that the tunneling conductance has a linear temperature dependence in the low energy and low temperature limit.Comment: 12 pages, Revtex, no figures, to appear in Phys. Rev.

Van alle markten thuis?

Zorgaanbieders moeten succespercentages en complicatierisico’s van operaties openbaar maken. Daarnaast zouden zorgverzekeraars meer zorg moeten afnemen van succesvolle en efficiënte zorgaanbieders. Dat stelt gynaecoloog prof. dr. Huub van der Vaart van het UMC Utrecht in zijn oratie donderdag 8 november aan de Universiteit Utrecht. “Kwaliteit van zorg betekent voor mij vooral gezondheidswinst voor de patiënt”, zegt Van der Vaart. “Maar artsen en ziekenhuizen zijn hier vaak niet transparant over. Artsen vertellen liever over de juiste procedures die ze hanteren, dan over de directe uitkomsten van hun behandelingen. Dat maakt het voor patiënten en zorgverzekeraars lastig om de beste artsen te kiezen.

Deep learning enables automatic quantitative assessment of the puborectalis muscle and the urogenital hiatus in the plane of minimal hiatal dimensions

OBJECTIVES: Measuring the length, width and area of the urogenital hiatus (UH), and the length and mean echo intensity (MEP) of the Puborectalis muscle (PRM) automatically and observer independently in the plane of minimal hiatal dimensions from transperineal ultrasound (TPUS) images by automatic segmentation of the UH and the PRM using deep learning. METHODS: In 1318 3D/4D TPUS volume datasets, images of the plane of minimal hiatal dimensions were manually obtained and the UH and the PRM were manually segmented. Those images were obtained from 253 nulliparae at 12 and 36 weeks pregnancy with the PRM at rest, contraction and Valsalva. A total of 713 images were used to train a convolutional neural network (CNN) to automatically segment the UH and the PRM in the plane of minimal hiatal dimensions. In the remaining dataset (test set 1, TS1, 601 images, 4 images were excluded), the performance of the CNN was evaluated and compared to the manual segmentations. The performance of the CNN was also tested on 119 images of an independent dataset of 40 nulliparae at 12 weeks pregnancy. This dataset was acquired and manually segmented by another different observer (TS2, 2 images were excluded). For these segmentations, the segmentation success was manually scored. Based on the CNN segmentations the following clinically relevant parameters were measured; the length, width and area of the UH, and the length and mean echo intensity of the PRM. The overlap (Dice similarity index (DSI)), surface distance (mean absolute distance (MAD) and Hausdorff distance(HDD)) between manual and CNN segmentations were measured to investigate the similarity of both segmentations. For the measured clinically relevant parameters, the intraclass correlation coefficients (ICC) between manual and CNN results were determined. RESULTS: Fully automatic CNN segmentation was successful in 99.0% and 93.2% for TS1 and TS2, respectively. DSI, MAD and HDD showed good overlap and distance between manual and CNN segmentations in both test sets. This was reflected in the ICC values of the length (0.96 resp. 0.95), width (0.77 resp. 0.87) and area (0.96 resp. 0.91) of the UH and the length of the PRM (0.87 resp. 0.73) and the MEP (0.95 resp. 0.97), which showed a good to very good agreement. CONCLUSION: Deep learning can be used to automatically and reliably segment the PRM and UH in 2D, in the plane of minimal hiatal dimensions, of the nulliparous female pelvic floor. These segmentations can be used to reliably measure the parameters; hiatal dimensions, PRM length and MEP. This article is protected by copyright. All rights reserved

Predicting who will undergo surgery after physiotherapy for female stress urinary incontinence

Contains fulltext : 153685.pdf (publisher's version ) (Closed access)INTRODUCTION AND HYPOTHESIS: To predict who will undergo midurethral sling surgery (surgery) after initial pelvic floor muscle training (physiotherapy) for stress urinary incontinence in women. METHODS: This was a cohort study including women with moderate to severe stress incontinence who were allocated to the physiotherapy arm from a previously reported multicentre trial comparing initial surgery or initial physiotherapy in treating stress urinary incontinence. Crossover to surgery was allowed. RESULTS: Data from 198/230 women who were randomized to physiotherapy was available for analysis, of whom 97/198 (49 %) crossed over to surgery. Prognostic factors for undergoing surgery after physiotherapy were age <55 years at baseline (OR 2.87; 95 % CI 1.30-6.32), higher educational level (OR 3.28; 95 % CI 0.80-13.47), severe incontinence at baseline according to the Sandvik index (OR 1.77; 95 % CI 0.95-3.29) and Urogenital Distress Inventory; incontinence domain score (OR 1.03; per point; 95 % CI 1.01-1.65). Furthermore, there was interaction between age <55 years and higher educational level (OR 0.09; 95 % CI 0.02-0.46). Using these variables we constructed a prediction rule to estimate the risk of surgery after initial physiotherapy. CONCLUSION: In women with moderate to severe stress incontinence, individual prediction for surgery after initial physiotherapy is possible, thus enabling shared decision making for the choice between initial conservative or invasive management of stress urinary incontinence

Chirurgie of fysiotherapie voor stressincontinentie. Wat is de behandeling van eerste keuze bij vrouwen.

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