Diagnosis and conservative management of female stress urinary incontinence

Urinary incontinence affects 17–45% of women worldwide and stress urinary incontinence is responsible for 48% of all cases. Detailed history, physical examination and investigations are crucial to identify the diagnosis underlying the incontinence symptoms to select effective therapy. Although mid-urethral sling procedures are considered to be ‘gold standard’ treatment of SUI, conservative treatment with pelvic floor muscle training and lifestyle modification is still the first line of management. This article discusses the diagnosis and conservative management of female SUI

Influence of anterior vaginal mesh with concomitant mid-urethral sling surgery on stress urinary incontinence: Clinical and sonographic outcome

Introduction To clinically and sonographically evaluate the influence of anterior vaginal mesh (AVM) surgery with concomitant mid-urethral sling surgery (MUS) for stress urinary incontinence (SUI). Materials and Methods Women with severe symptomatic pelvic organ prolapse (POP) stage III or IV with concomitant SUI were divided into two groups: Group I had transobturator tape (TOT) and AVM surgery and Group II underwent TOT without AVM surgery. Clinical outcome was assessed pre-operatively and 1 year post-operatively, while ultrasound evaluations were performed after one year. Objective cure was defined as no urinary leakage demonstrable on provocative filling cystometry. Subjective SUI cure was a negative response to Urogenital Distress Inventory Six (UDI-6) (question 3). Results A total of 97 women were recruited, 57 in Group I and 40 in Group II. Three women had symptomatic prolapse in Group I and 5 in Group II. There were no differences in the ultrasound and clinical outcomes between women who had mid-urethral slings with and without AVM. Successful SUI outcome was reported in 85 women. Urethral kinking was demonstrable in 50% of successful cases, but none with failed outcomes. Subanalysis among those with successful SUI outcome (n = 85) and failure (n = 12) revealed the tape, bladder neck and mesh mobility was significantly higher (P \u3c 0.001) among those with SUI success. Conclusions Among women who had MUS, there were no differences in the ultrasound and clinical outcome between those who had AVM or otherwise

Assessment of collagen versus non collagen coated anterior vaginal mesh in pelvic reconstructive surgery: Prospective study

Objective To evaluate the sonologic and clinical outcome of collagen coated (CC) versus non-collagen coated (NC) anterior vaginal mesh (AVM) for pelvic organ prolapse (POP) surgery. Study design The study is a prospective observational study which included 122 patients who had symptomatic POP stage III and IV. AvaultaPlus™ (collagen coated, CC group) was compared to Perigee™ (non collagen coated, NC group). Introital ultrasound morphology, measure of neovascularization by color Doppler and clinical outcomes were assessed. Student t test was used for comparison of pre- and post-operation continuous data (p value of \u3c0.05). Results A total of 110 (CC group = 50, NC group = 60) women completed the study. A woman in the CC group developed ureteral injury. Both groups had comparable morphologic and clinical outcomes however, the onset of changes in mesh thickness and neovascularization occurred earlier in the NC group (1 month) compared to the CC group (6 months to 1 year). Conclusion CC group was comparable to the NC group in terms of erosion rate, ultrasound and clinical assessment. Collagen coating may induce delayed inflammatory response however may also delay tissue integration. The onset of changes in mesh thickness and neovascularization may give us an insight toward utilization of collagen coated mesh for host-tissue integration

Clinical outcomes of mesh exposure/extrusion: Presentation, timing and management

Background: The Food and Drug Administration has recently highlighted an increase in reported complications associated with the use of transvaginal mesh. Aims: To describe the clinical outcomes, presentation, timing and management of mesh exposure/extrusion Materials and Methods: Retrospective study from December 2006 to March 2012. A total of 40 women had vaginal mesh exposure/extrusion secondary to prior transvaginal mesh (TVM) surgery. Descriptive statistics were used for demographics and pre-operative data. Paired-samples t-test was applied for comparison of pre- and postoperation. A P value of \u3c0.05 was considered statistically significant. Results: The mesh exposure/extrusion rate was noted to be 2.64% (17/642). Vaginal bleeding in 29 of 40 (72.5%) and hispareunia in 12 of 13 (92.3%) were identified as the most common symptoms for mesh exposure/extrusion. The onset of complications occurred in two peaks: between 3 and 4 months and after 1-year of follow-up. Initial conservative treatment was given for 12.5% (5/40) of women, while 87.5% (35/40) had undergone repair for mesh exposure/extrusion (21 outpatient and 14 inpatient cases). Among those who had conservative treatment, 80% (4/5) had persistent mesh exposure. Conclusion: Persistent or new-onset abnormal vaginal bleeding and hispareunia after TVM surgery should be considered as \u27red flag\u27 symptoms for mesh exposure/extrusion. Frequent follow-up from the first 3-4 months up to 1 year postoperative may identify complications. Utilisation of mesh excision or trimming as the initial means of treatment may yield a better outcome

Assessment of Collagen-Coated Anterior Mesh Through Morphology and Clinical Outcomes in Pelvic Reconstructive Surgery for Pelvic Organ Prolapse

Study Objective: To assess the morphologic features of anterior armed transobturator collagen-coated polypropylene mesh and its clinical outcomes in pelvic reconstructive surgery to treat pelvic organ prolapse. Design: Evidence obtained from several timed series with intervention (Canadian Task Force classification II-3). Setting: Chang Gung Memorial Hospital, Taoyuan, Taiwan, China. Patients: Between April 2010 and October 2012, 70 patients underwent surgery to treat symptomatic pelvic organ prolapse, stage III/IV according to the POP-Q (Pelvic Organ Quantification System). Intervention: Anterior armed transobturator collagen-coated mesh.Measurement and Main Results: Morphologic findings and clinical outcome were measured. Morphologic features were assessed via 2-dimensional introital ultrasonography and Doppler studies. Clinical outcome was measured via subjective and objective outcome. Objective outcome was assessed via the 9-point site-specific staging method of the International Continence Society Pelvic Organ Prolapse Quantification before the operation and at 1-year postoperative follow-up. Subjective outcome was based on 4 validated questionnaires: the 6-item UDI-6 (Urogenital Distress Inventory), the 7-item IIQ-7 (Incontinence Impact Questionnaire), the 6-item POPDI-6 (Pelvic Organ Prolapse Distress Inventory 6), and the 12-item PISQ-12 (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire), at baseline and at 12months after the operation. Data were obtained for 65 patients who underwent the combined surgery and were able to comply with follow-up for \u3e1year. Ultrasound studies reveal that mesh length tends to shorten and decrease in thickness over the 1-year follow-up. Vagina thickness also was reduced. Neovascularization through the mesh was observed in \u3c8.5% of patients in the first month and at 1year, and was evident in approximately 83%. The mesh exposure rate was 6.4%. The recorded objective cure was 90.8% (59 of 65 patients), and subjective cure was 89.2% (58 of 65 patients) at mean (SD) follow-up of 19.40 (10.98) months. At 2years, UDI-6, IIQ-7, and POPDI-6 scores were all significantly decreased (p\u3c.001), whereas the PISQ-12 score was significantly increased (p=.01). Conclusions: Ultrasound features suggest that the degeneration of collagen barrier may be longer than expected and that integration of collagen-coated mesh could occur up to 1year. A substantially good clinical outcome was noted

Anterior-apical single-incision mesh surgery (SIMS): Surgical and functional outcomes at 1 year

Study Objectives: To study the surgical and functional outcomes of single-incision mesh surgery for treatment of advanced pelvic organ prolapse (POP). Design: Case series (Canadian Task Force classification II-3). Setting: University hospital. Patients: Sixty-five patients who underwent surgery to treat symptomatic POP greater than stage II according to the Pelvic Organ Prolapse Quantification System (POP-Q). Intervention: All patients underwent anterior-apical single-incision mesh surgery using the Elevate Anterior and Apical Prolapse Repair System. Measurements and Main Results: The 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 6months 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 \u3c .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 \u3c .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. Conclusions: Single-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

Ultrasonography and clinical outcomes following surgical anti-incontinence procedures (Monarc vs Miniarc)

Objective To evaluate the ultrasound morphology and its clinical outcome among women who had undergone Miniarc™ vs Monarc™ in the treatment of stress urinary incontinence (SUI). Study design This was a prospective study on 140 patients with USI and undergone either Miniarc or Monarc surgery. From March 2010 to December 2011, patients with clinically SUI and urodynamic stress incontinence (USI) were included in the study. Objective cure of SUI was defined as no urinary leakage on provocative filling cystometry and 1-h pad test of \u3c2 g. Subjective cure of SUI was the negative response to UDI-6. Introital ultrasound at one-year explored the sling and bladder neck\u27s position, mobility, sling tension, percentile of urethra where the sling was located and urethral kinking. Results Postoperative data was available from 130 women. The ultrasound objective data for successful treatment post-operative follow-up was available from 119 women (46 Monarc, 73 Miniarc), the rest failed to follow-up. A bladder perforation was diagnosed in the Monarc group and 15 cases (7.1% of Monarc and 16.3% of Miniarc, p = 0.082) of urinary retention was reported due to over-tensioning of the sling, majority of cases came from the Miniarc group. At rest and during Valsalva, analogous distances of the bladder neck and sling as well as the center of the urethral core were similar for both procedures. In both groups, shortest (Us) and longest diameters (Ul) of the urethral core were comparable at Valsalva which was significantly shorter and longer, respectively, compared to the values at rest. Sling position and percentage of urethral kinking were similar. Statistical analysis failed to detect any significant difference between the two groups with regards to the objective and subjective cure (p \u3e 0.05). Conclusions In conclusion, a Miniarc and Monarc exhibit similar mechanism of action with comparable subjective and objective clinical outcomes. Majority of urethral impingement was noted in the Miniarc group. A higher maximum urethral closure pressure (MUCP), longer resting Ul, and shorter resting Us suggested these observations. Postoperative ultrasonographic evaluation may give a promising future perspective for the evaluation of sling tension

Comparison between Elevate Anterior/Apical system and Perigee system in pelvic organ prolapse surgery: clinical and sonographic outcomes

Objective: The aim of this study was to assess the incidence of de novo stress urinary incontinence (SUI) and sonographic features of implanted transvaginal mesh in continent women treated with Elevate™ anterior/apical [single-incision mesh (SIM-A)] or Perigee™ [transvaginal mesh with sacrospinous fixation (TVM + SSF)] in extensive pelvic organ reconstruction surgery. Methods: This prospective observational study was done from May 2010 to January 2013. Patients were recruited from two tertiary centers, and the Elevate™ and Perigee™ systems were compared. Patients who had overt or occult SUI, previous prolapse or mesh insertion were excluded. Result: Fifty-seven patients in the SIM-A group and sixty-one in the TVM + SSF group were analysed. All completed a minimum of 1-year follow-up. Groups were demographically and statistically similar. There was a significantly high incidence of de novo SUI postoperatively in the SIM-A group. The objective and subjective cure rate of pelvic organ prolapse (POP) were comparable between groups, with incidence of mesh erosion in the SIM-A group and three in the TVM + SSF group. Sonographic evaluation showed significant increase in mesh length in the SIM-A group. Conclusion: Elevate™ a offered lower incidence of mesh erosion and comparable results on anatomical POP correction; however, incidence of de novo SUI was high. There is an apparent lengthening of implanted Elevate® mesh sonographically

Clinical outcomes of single-incision sling procedure (MiniArc)

Objective: To evaluate the clinical outcome among women who had undergone Miniarc™ in the treatment of stress urinary incontinence (SUI). Study design: In this retrospective study from March 2010 to December 2011 patients with clinically confirmed SUI and urodynamic stress incontinence (USI) underwent Single Incision Sling Procedure (SIS). Objective cure of SUI was defined as no urinary leakage on provocative filling cystometry and 1-hour pad test of <2 g. Subjective cure of SUI was the negative response to UDI-6. Assessment was done at baseline and after 1 year follow-up. Results: Postoperative data was available for 85 women. Five women were not able to participate in the follow-up schedule and post-op questionnaire. The objective data for post-operative follow-up was available from 80 women. The average period of follow-up was 1.4 years (range 1.0 to 2.1). A total of 14 women had immediate post-operative urine retention at the first 24 hours and 6 cases were due to over-tensioning of the sling after ultrasound assessment. No case of bladder or bowel injury was recorded and no other major complications noted. Pre and post clinical findings revealed a significant improvement after 1 year follow-up based on the response to UDI-6, IIQ-7 ( 0.05). Conclusions: In conclusion, Miniarc™ was noted to have improvement in both subjective and objective clinical outcomes. Urethral indentation was noted and resolved by tape release on immediate post-operative voiding dysfunction