[show abstract][hide abstract] ABSTRACT: The purpose of this study was to assess the effect of pregnancy and first vaginal delivery on urethral striated sphincter neuromuscular function.
Quantitative electromyographic (EMG) interference pattern analysis of the urethral sphincter of 23 nulligravidas and 31 third trimester primigravidas allowed comparison of mean motor unit parameters before term vaginal delivery and postpartum.
Mean electromyographic interference pattern parameters in the primigravidas were significantly lower than nulligravidas even antepartum, with decreased turns, lower amplitude, and less activity. The only significant change at 6 months' postpartum was further decline in number of turns resulting in a further decrease in turns:amplitude. All other electromyographic abnormalities persisted at 6 months' postpartum and remained abnormal compared to the nulligravidas.
Urethral sphincter neuromuscular function changed significantly during pregnancy and these changes persisted postpartum. Lack of recovery 6 months' postpartum suggests a physiologic impact of pregnancy itself on future risk of urinary incontinence.
American journal of obstetrics and gynecology 09/2009; 201(5):529.e1-6. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: The objective of the study was to assess the prevalence of levator ani denervation and reinnervation 6 months after the first delivery.
Ninety-six primigravida women underwent quantitative electromyography of the levator ani during the third trimester and twice postpartum. A 95% confidence interval for normal function was created using interference pattern analysis. Fifty-seven who completed the study are presented in this secondary data analysis. Postpartum muscle sites outside the normal range were considered abnormal. Obstetric and demographic characteristics were assessed.
Of 57 subjects, 70% had no denervation. Of the 30% with denervation at 6 weeks, 35% recovered by 6 months. Obstetric or maternal characteristics were not predictive of denervation or reinnervation, except subjects with persistent denervation tended toward lower body mass index (BMI) independent of mode of delivery.
Nearly one-third of women have levator ani denervation after first delivery, but many recover by 6 months. Denervation is not clearly associated with mode of delivery, but higher maternal BMI may be protective.
American journal of obstetrics and gynecology 04/2009; 200(5):519.e1-7. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: Lower urinary tract symptoms (LUTS) occur in 5-20% of women after antiincontinence procedures. Symptoms include complete urinary retention or storage, voiding, and postmicturition symptoms. The goal of this study was to determine the effect of time from sling placement to midline sling lysis on overall improvement in LUTS.
After institutional review board approval, we conducted a retrospective cohort analysis of 112 subjects undergoing midline sling lysis from January 1997-September 2007. The inclusion criteria were women with a vaginal midline sling lysis for LUTS after a prior pubovaginal or midurethral sling. We excluded any subject with sling erosion without LUTS and those who underwent a repeated sling at the time of lysis. We compared subjects who had an early sling lysis (< or = 1 year from sling to lysis) to a late sling lysis (> 1 year). The primary outcome was based on the subject's report of overall improvement in symptoms. We abstracted data on demographics, presenting symptoms, physical examination, date of antiincontinence procedure, date of midline sling lysis, and postoperative symptoms. Statistical analysis consisted of Student t test, chi(2) test, Fisher exact test, and multivariate logistic regression.
Of 112 subjects, 74 (66%) had an early sling lysis and 38 (34%) had a late sling lysis. These 2 groups were similar in age, menopausal status, presence of preoperative LUTS, anterior colporrhaphy at the time of lysis, and presence of an eroded sling. The early lysis group had a higher percentage of midurethral slings (36% vs 8%; P = .001), a lower rate of preoperative complete retention (70% vs 89%; P = .001), and a lower rate of prior urethrolysis (16% vs 45%; P = .003). No significant difference in follow-up time was found between early lysis compared with late lysis (49 +/- 89 months vs 43 +/- 71 months; P = .73). Ten (8.9%) subjects developed recurrent stress urinary incontinence after sling lysis, which was independent of time to lysis. In all, 94 (84%) subjects had improvement in their LUTS after midline sling lysis. Overall improvement occurred more often in the early sling lysis group compared with the late sling lysis group (91% vs 71%; P = .01). This finding retained significance in a multivariate logistic regression model, which included age, prior urethrolysis, preoperative complete retention, and type of sling (odds ratio, 4.0; 95% confidence interval, 1.2-13.2).
Based on this large cohort, patients may benefit from earlier midline sling lysis within 1 year for LUTS after a pubovaginal or midurethral sling procedure. The development of recurrent stress urinary incontinence after midline sling lysis is relatively low.
American journal of obstetrics and gynecology 02/2009; 200(5):564.e1-5. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: The purpose of this pilot study was to compare the efficacy of 2 techniques for evaluating bladder function after transvaginal surgery.
Subjects scheduled for transvaginal, outpatient surgery were consecutively enrolled and randomized to backfill-assisted voiding trial or a trial of spontaneous voiding after surgery.
Sixty subjects were enrolled. The mean time in the perioperative anesthesia care unit for the backfill group was 199.5 minutes vs 226.6 minutes in the spontaneous voiding group (P = .08). Subjects randomized to backfill were more likely to adequately empty their bladders and be discharged home without catheter drainage than subjects in the spontaneous voiding group (61.5% vs 32.1%, respectively, P = .02). Multiple logistic regression further demonstrated that the backfill-assisted technique predicted successful bladder emptying after vaginal surgery (P = .02).
Women undergoing transvaginal outpatient surgery are more likely to empty their bladder effectively before discharge if they are evaluated with a backfill-assisted voiding trial.
American journal of obstetrics and gynecology 01/2008; 197(6):627.e1-4. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: The aim of this study is to determine if urodynamic findings in patients with urge incontinence predicts response to sacral neuromodulation test stimulation. One hundred four patients with refractory urinary urge incontinence who had undergone sacral neuromodulation test stimulation were retrospectively reviewed. Pre- and post-test stimulation incontinence parameters and pelvic floor muscle (PFM) contraction strength was documented. Urodynamics were reviewed on all patients, and the presence or absence of detrusor overactivity (DO) was noted. Patients were then divided into two groups: responders to the test stimulation and non-responders. A positive response was considered to be a >or=50% improvement in the number of incontinent episodes per day (IE/day) and/or pad weight with test stimulation. Of the 104 patients evaluated, 64% (N = 67) responded to the test stimulation, while 36% (N = 37) were non-responders. The mean age was 59.7 and 67.0 among responders and non-responders (p = .01). There was a significant difference in the number of IE/day between non-responders and responders (p = .02). There was no relationship found between the presence or absence of DO and the likelihood for test stimulation success, patient demographics or pre test stimulation incontinence variables. Our study provides no statistically significant evidence that the presence or absence of DO on urodynamics predicts a response to sacral neuromodulation test stimulation. An important finding, however, was that patients without demonstrable DO on urodynamics may still have a positive response to sacral neuromodulation.
International Urogynecology Journal 01/2008; 18(12):1395-8. · 2.17 Impact Factor
[show abstract][hide abstract] ABSTRACT: We previously described an endoscopic-assisted transvaginal mesh excision technique. This study compares surgical outcomes after transvaginal mesh excision vs endoscopic-assisted transvaginal mesh excision. In addition, we reviewed our postoperative outcomes with excision via laparotomy.
This was an inclusive retrospective analysis of patients presenting to our institution from 1997 to 2006 for surgical management of vaginal erosion of permanent mesh after sacrocolpopexy. Three techniques were utilized: transvaginal, endoscopic-assisted transvaginal, and laparotomy. For the patients undergoing transvaginal excision, data recorded included number and type of excisions performed, number of prior excisions performed at outside facilities, intraoperative and postoperative complications (including blood transfusions, pelvic abscess, or bowel complications), use of postoperative antibiotics, persistent symptoms of vaginal bleeding and discharge at follow-up, and demographic characteristics. The intraoperative and postoperative complications and the postoperative symptoms were recorded for the laparotomy cases.
Thirty-one patients underwent transvaginal mesh excision during this time period: 17 endoscopic-assisted transvaginal and 14 transvaginal without endoscope assistance. In addition, a total of 7 patients underwent abdominal excision via laparotomy. Comparison of the 2 vaginal methods revealed no difference in the demographics or success rate, with success defined as no symptoms at follow-up. Endoscopic-assisted transvaginal excision was successful in 7 of 17 patients and transvaginal without endoscopic assistance in 9 of 13 patients (1 patient excluded for lack of follow-up data) for a total vaginal success rate of 53.3%. No intraoperative and only minor postoperative complications occurred with either vaginal method. Three patients underwent 3 vaginal attempts to achieve complete symptom resolution. The average follow-up time for the entire vaginal group was 14 months. Seven patients ultimately required abdominal excision and all had symptom resolution, however, not without complications. Two patients had bowel injury during lysis of adhesions requiring bowel resection in 1 case and repair in another, 1 had a postoperative wound infection with breakdown, 1 was readmitted for postoperative fever requiring antibiotics, and 1 had an acute coronary syndrome requiring transfer to the cardiology service.
Transvaginal excision of mesh with or without endoscopy appears to be a safe and less invasive method for excision of eroded vaginal mesh after prior abdominal sacrocolpopexy. Up to 3 vaginal excision attempts may be necessary to achieve symptom resolution, and complete removal of mesh will likely improve outcomes with the transvaginal technique. Although abdominal excision can be considered the gold standard for excision of eroded mesh, it is not without potentially increased morbidity.
American journal of obstetrics and gynecology 01/2008; 197(6):615.e1-5. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: Pelvic organ prolapse has afflicted women since the beginning of mankind. Even though we have been faced with this problem for so many centuries, we still have not found a way to overcome gravity and prevent prolapse. We continue to make efforts to manage prolapse, modifying our techniques based on burgeoning research. This knowledge helps us to avoid repetitive complications from surgery and to improve techniques to prevent recurrent prolapse. In addition, we are constantly adapting our methods depending on available technology. With an aging population, the demand for physicians and surgeons trained in management of pelvic organ prolapse will increase. The rapidly evolving literature on pelvic organ prolapse makes a comprehensive review difficult. However, based on the current literature, randomized controlled trials are needed to compare new prolapse repair techniques to traditional techniques. Physicians specializing in surgical management of pelvic organ prolapse will need to work together to complete quality clinical trials. The primary focus of this review will be on the recent research concerning the epidemiology, etiology, presenting symptoms, and diagnosis of pelvic organ prolapse. We will also discuss the different types of prolapse by compartments of the vagina in which they occur and how each of these types of prolapse can be managed. Finally, we will review recent literature evaluating surgical repairs using transvaginal mesh kits.
[show abstract][hide abstract] ABSTRACT: Assess postpartum changes in the levator ani muscle using magnetic resonance imaging and relate these changes to obstetric events and risk factors associated with pelvic floor dysfunction.
A board-certified radiologist specializing in abdominal imaging evaluated 146 pelvic magnetic resonance studies from 57 primiparous women 6 weeks and 6 months after first obstetric delivery and 32 nulliparous women. A yes/no determination of muscle body and insertion integrity, muscle thinning, and measurement of muscle thickness in millimeters was made for each of 4 muscle sites: right and left puborectalis and right and left ileococcygeous. Incidence of muscle abnormality and mean muscle thickness was tested in pairs between (1) nulliparous women and 6-week primiparous women; (2) 6 week and 6 month primiparous pairs; and (3) 3 age/race groups using test of 2 proportions and 1-way analysis of variance.
Initial review indicated only 3 subjects not of African American or white race, and only 1 African American primiparous woman of age 30 years or older; therefore, statistical analysis was limited to 45 primiparous women and 25 nulliparous women. Incidence of any abnormality at any of the 4 sites was considered abnormal. In those subjects recovering to normal magnetic resonance by 6 months, an average of nearly 60% increase in right puborectalis muscle thickness compared with that seen at 6 weeks indicated the extent of the injury. Subjects with injury to both the puborectalis and ileococcygeous at 6 weeks did not recover to normal at 6 months, whereas those with injury only to the puborectalis tended to have normal magnetic resonance images at 6 months.
Nulliparity did not guarantee a normal assessment of levator ani anatomy by our blinded reader, and frequency of injury in this series is somewhat greater than that previously reported for primiparous women. Younger white primiparous women had a better recovery at 6 months than older white women. Subjects experiencing more global injury, in particular to the ileococcygeous, tended not to recover muscle bulk.
American journal of obstetrics and gynecology 08/2007; 197(1):65.e1-6. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: Pelvic organ prolapse is an increasingly common problem as women are living longer. With the growing numbers of surgeries performed to correct this problem, further research is needed to understand the long-term success as well as possible complications of these procedures. One potential complication that needs further study is de novo rectal prolapse after repair of pelvic organ prolapse, specifically after colpocleisis. Defacography may be an important part of the preoperative workup in the patient with pelvic organ prolapse. Currently, there is a controversy as to whether internal, or occult, rectal prolapse on defacography should be repaired at the time of other pelvic reconstructive surgery. We report on a case of overt rectal prolapse after repair of Stage IV vaginal vault prolapse with a colpocleisis, levator ani plication, and a minimally invasive midurethral sling. We discuss the issues surrounding preoperative management of these patients and propose a theory explaining why prolapse in other areas of the pelvis may occur after reconstructive surgery.
International Urogynecology Journal 05/2007; 18(4):471-3. · 2.17 Impact Factor
[show abstract][hide abstract] ABSTRACT: We measured levator ani neuromuscular function before and after first delivery to identify the location, timing, and mechanism of injury.
Fifty-eight primiparous women underwent electromyographic examination of the levator ani antepartum at 6 weeks and 6 months after the delivery. Antepartum turns/amplitude data were pooled to create a normal range. We calculated each woman's percentage of outliers from this range and assessed relationships between delivery and extent of injury.
At 6 weeks, 14 of 58 women (24.1%) had neuropathy, with 9 of those 14 women recovering by 6 months. At 6 months, 17 of 58 women (29.3%) were neuropathic, which included 12 new injuries. Women who had elective cesarean delivery had virtually no injury, but all other modes of delivery had similar injury rates.
Obstetric delivery is associated frequently with electromyographic evidence of neuropathic injury to the levator ani. The entire levator complex is at risk, and cesarean delivery while in labor is not protective.
American journal of obstetrics and gynecology 01/2007; 195(6):1851-6. · 3.28 Impact Factor