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Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals
Abstract
To evaluate the prevalence of prolapse and related bladder, bowel, and sexual problems in transsexual patients (TS) after sex reassignment surgery.
A cross-sectional study.
A tertiary referral center.
55 transsexuals, comprising 52 male-to-female and 3 female-to-male patients.
Gynecologic examination with pelvic floor testing, measurements for pelvic organ prolapse applying International Continence Society pelvic organ prolapse (ICS-POP) staging, and the Sheffield prolapse questionnaire to assess prolapse symptoms, and bladder, bowel, and sexual function.
ICS-POP score and Sheffield prolapse questionnaire.
Of the 55 transsexuals who participated in this study (52 male-to-female and 3 female to male), 7.5% showed a prolapse greater than or similar to ICS-POP stage 2, and 3.8% required surgical intervention. For bladder symptoms, 47% reported voiding difficulties, 24.6% urgency, 17% urge incontinence, and 23% stress incontinence. Fecal urgency and incomplete emptying of the bowel occurred in 9.4% and 7.6% of patients, respectively. In addition, 23% reported that they were never satisfied with their sexual function.
Pelvic floor symptoms may occur in transsexuals involving the bladder, bowel, and sexual function. Surgical corrective options should be determined on an individual basis as with other patients who have prolapse symptoms.
... One hypothesis is that the mental burden associated with additional unforeseen surgery due to complications may have a long time effect on the mental health of trans individuals. Although recent literature indicates that the number of surgical interventions for reasons of corrections or complications may be high in trans men [14] as well as in trans women [15], we can hypothesize that trans men suffer more from this burden compared with trans women. Another hypothesis to explain the consistent findings of trans men having a diminished mental healthrelated QOL is that these findings represent an increased rate of underlying depressive disorders for trans men compared with male controls. ...
Studies show a positive impact of gender reassignment treatment on the quality of life (QOL) of transgender persons, but little is known about the influence of their socioeconomic status.
First, to assess health-related QOL of transgender men and women and compare it with a general population sample, second, to investigate the differences between transgender men and transgender women, and third, to analyze how their levels of QOL differ according to socioeconomic and transition data.
One hundred forty-eight current and former transgender patients of a gender identity clinic participated in a large QOL study.
Health-related QOL was measured using the Short Form 36-Item Questionnaire.
The QOL of transgender women did not differ significantly from the general Dutch female population, although transgender men showed reduced mental health-related QOL compared with the general Dutch male sample. Transgender women had a lower QOL than transgender men for the subscales physical functioning and general health, but better QOL for bodily pain. Time since start of hormone use was positively associated for transgender women with subscales bodily pain and general health, and negatively associated for transgender men with the subscale role limitations due to physical health problems. There was no significant difference in QOL between the group who had undergone genital surgery or surgical breast augmentation and the group who did not have these surgeries. Transgender men with an erection prosthesis scored significantly better on the subscales vitality and (at trend level) on role limitations due to emotional problems. A series of univariate analyses revealed significantly lower QOL scores for transgender persons that were older, low educated, unemployed, had a low household income, and were single.
Specific social indicators are important in relation to health-related QOL of transgenders in a context of qualitative and adequate medical care.
... By controlling the duration of surgery, surgical intervention in transgenders had no significant relationship with any of the subscales of QoL that is in line with several studies [24,28,30,31] and antithetical to the results of other studies [23,25,27,32]. Transgender people who had both upper and lower sex reassignment surgery had a better QoL than the control group. ...
Background:
The aim of this study was to evaluate the self-reported perceived quality of life (QoL) in female to male (FTM) and male to female (MTF) transgenders and compare it with a general population sample, and to find possible determinants that likely contribute to their QoL.
Methods:
Participants were 71 trandgenders participating in the communities of Isfahan and Fars provinces, Iran, including 30 MTF and 41 FTM, and 142 gender- and age-matched controls. Persian version of the Short Form 36-Item Questionnaire was used to evaluate self-reported QoL, which measures QoL across eight domains.
Results:
Compared to control group, the QoL of transgenders in the most dimensions of the SF-36 questionnaire was lower. MTF had a lower QoL than FTM for the subscale physical functioning (p = 0.044). There was a significant relationship between education and subscales of emotional well-being (p = 0.048) and social function (p = 0.008); economic status and physical function subscale (p = 0.003); employment status and physical function (p = 0.012) and social function subscales (p = 0.003). Compared to male controls, MTF transgenders had lower physical functioning (P < 0.001), role limitation due to physical health (P = 0.015), vitality (P = 0.023), social functioning (P < 0.001) and pain score (P = 0.044) and no significant differences between female controls and FTM transgenders were seen.
Conclusion:
Transgenders have lower physical and mental QoL, FTM transgender has better QoL than MTF transgender. Employment, education, province of residence and economic status as well as therapeutic intervention is associated with transgender's QoL.
... This potential space is located between the double layers of Denonvilliers' fascia, which comes down between the rectum and the prostate as far as its apex [5]. Motor, sensory, and autonomic innervations of the pelvic organs course laterally from the pelvic side wall and are situated in this fascia at the posterolateral area of the prostate [6]. Autonomic and pelvic nerve preservation is a major concern for coloproctologists, urologists, and gynecologists during pelvic dissection. ...
Background: Male-to-female sex reassignment surgery (MTF-SRS) is a treatment for gender identity disorders (GID) wherein the penis is removed and an epithelialized neovagina is created in the retroprostatic or rectovesical space. This is a space between the double layers of Denonvilliers’ fascia that contains motor, sensory, and autonomic nerves to the pelvic organs. Injury to these nerves may lead to anorectal dysfunction. However, there has been no objective study of anorectal physiologic changes after SRS.
Objectives: To compare anorectal physiological parameters, before and after, male-to-female sex reassignment surgery (SRS) and to evaluate the effects of SRS on anorectal physiology.
Methods: In 10 patients with MTF GID who underwent SRS at King Chulalongkorn Memorial Hospital, anorectal manometry was performed using a water perfused catheter (Mui Scientific, Ontario, Canada) and a state-of-the-art anorectal manometry system (Medtronic, Minneapolis, MN, USA) at the Gastrointestinal Motility Research Unit at 2 weeks before and 3 months after the SRS. Data were analyzed using PolygramNet software. Anal sphincter pressures (mmHg) with volume used to elicit rectal sensation (mL).
Results: There was no significant change in the resting anal sphincter pressure, anal sphincter squeezing pressure, sustained squeezing pressure, and duration of squeeze, rectal sensation, and threshold of the desire to defecate affected by SRS. Cough reflex and rectoanal inhibitory reflex were normal both before and after SRS in all patient participants.
Conclusions: Sex reassignment surgery seems to produce no effect on clinical anorectal functions. This was proven by absence of clinically significant changes in anorectal manometry.
... Empirically, dilatation has limited effect in increasing depth but is necessary to prevent reduction of the vaginal space or, in worst case, even collapse and protrusion. 18,19 In comparison to surgical techniques using scrotal flaps or skin grafts, our postoperative dilatation protocol is not significantly different. 20 The use of pedicled intestinal tissue 7,21 may limit the need for postoperative dilatation but impose possible long-term risks of colitis 22 and a perceived increased morbidity by operating intraabdominally. ...
Background:
Gender reassignment surgery due to transsexualism (International Classification of Diseases, Tenth Revision: F64.0) is a procedure becoming increasingly common worldwide as a result of a significant increase in diagnostic incidence. Several methods have been described for this complex surgery, but no internationally agreed upon gold standard exists, in particular with regard to which methods allow for creating a sufficient neovaginal depth.
Methods:
We use a 2-stage technique using solely penile skin for creating a neovaginal cavity and present the long-term outcome in terms of measured neovaginal depth. Eighty patients were included. Patients' neovaginal depth was measured in a standardized fashion 6 months or more after initial surgery. Results were compared with published data on female anatomy.
Results:
The average neovaginal depth achieved was 10.2 cm. Having had a postoperative complication and noncompliance to neovaginal dilatation were both negatively correlated with neovaginal depth, whereas higher body mass index was not. Most patients received a neovaginal depth sufficient for penetrative intercourse and within the range for biological women.
Conclusions:
Using solely penile skin for the vaginal lining is a satisfactory surgical method to achieve adequate vaginal depth, provided that the postoperative dilatation regimen is followed. This holds true regardless of age or body mass index.
... Little data exist on the prevalence and management of pelvic floor symptoms and disorders following vaginoplasty surgery. The largest study published by Kuhn et al. looked at the prevalence of prolapse and bladder, bowel, and sexual dysfunctions following vaginoplasty surgery using the penoscrotal inversion technique [8]. In this cohort study, 52 male-tofemale patients were assessed with pelvic floor and gynecologic examinations and validated pelvic floor questionnaires. ...
Purpose of Review
This paper aims to review the current data that exist on the urogynecologic needs of the transgender patient and to relay important clinical pearls that may be useful to assist providers in caring for this patient population.
Recent Findings
In one study, 7.5% of transgender women who had undergone vaginoplasty surgery had a stage 2 or greater prolapse; 3.8% required surgery to repair their prolapse; 47% reported voiding dysfunction; 25 and 17% reported urinary urgency and urge incontinence, respectively; and 23% had stress incontinence. In a large cohort of patients who had undergone vaginoplasty, the overall incidence of rectoneovaginal fistula was 1.2% (95% CI 0.6, 2.1) and revision surgery was more likely to be associated with the development of a fistula. The complications most associated with phalloplasty procedures performed in female-to-male patients are urethrocutaneous fistulae (22 to 75%) and urethral stricturing (25 to 58%).
Summary
Data on pelvic floor disorders as they relate to transgender patients is sparse; however, as we begin to see more and more of these patients in academic centers, their medical needs are being studied and the literature on this patient population is slowly becoming more robust.
... Baranyi, Piper & Rothenhäusler (2009, pp.548-57) afirmaM que os procedimentos para a mudança de sexo são penosos, com pósoperatório demorado e nem sempre o resultado final -mesmo que esteticamente bom -apresentase funcional. Outro estudo demonstra que pessoas com transexualismo, depois de redesignação de sexo, têm riscos consideravelmente mais elevados de mortalidade, comportamento suicida e morbidade psiquiátrica do que a população em geral (Kuhn, Santi & Birkhäuser, 2011, pp.2379. Não basta, portanto, que candidatos à cirurgia preencham os critérios da elegibilidade. ...
Introdução: Visando promover o bem estar da população transexual, mundialmente há alterações nas recomendações de condutas clínicas. Os critérios para os tratamentos visam minimizar os efeitos da Disforia de Gênero desta população resguardando-lhes o direito à dignidade humana, e devem ser adotados pelas condições de elegibilidade e de presteza; dentre eles, a complexa Cirurgia de transgenitalização. Objetivo: Discutir a atípica situação de sujeito transexual que não deseja passar pelo procedimento cirúrgico. Método: Emprego de entrevista qualitativa que visou estudar as relações dos significados atribuídos pelo sujeito da pesquisa. Resultados: Relato de Caso descritivo de sujeito que se contrapõe a um dos elementos do diagnóstico psiquiátrico de transexualismo: atendendo aos critérios de elegibilidade à transgenitalização prefere conservar suas características físicas, mas mantém uma atitude positiva em relação ao seu corpo devido a eficiência de suas defesas psicológicas. Conclusão: Este caso nos convida a refletir que a mudança de sexo, apesar de aliviar a disforia de gênero, pode não ser suficiente como tratamento para o transexual. A recomendação do tratamento deve ir além da elegibilidade e deve avaliar o préstimo ofertado à qualidade de vida do sujeito dentro de novas perspectivas despatologizadas promovidas por entidades de cuidado humanitário na área da saúde. Introduction: Intending to promote the welfare of the transsexual population there are worldwide changes in clinical management recommendations. The criteria for treatments aim at minimizing the effects of Gender Dysphoria of this population safeguarding their right to human dignity and shall be adopted by the conditions of eligibility and readiness; the complex sex reassignment surgery is among these treatments. Objective: To discuss the atypical situation of a transsexual subject who does not want to go through the surgical procedure. Method: Use of qualitative interview aimed at studying the relationships of meanings attributed by the research subject. Results: Descriptive Case Report of atypical subject opposed to one of the elements of the psychiatric diagnosis of transsexualism: meeting the eligibility criteria for gender reassignment, prefers to keep its physical characteristics but maintains a positive attitude to the body due to its efficient psychological defenses. Conclusion: This case invites us to reflect that sex change, although alleviating gender dysphoria, may not be sufficient as a treatment for the transsexual. The treatment recommendation must go beyond the eligibility and must assess the benefit offered to the quality of life of the subject within unpathologized new perspectives promoted by humanitarian organizations in health care.
... The complications of SRS may necessitate additional surgeries, with possible long-term outcomes on the mental health of transsexual people. Overall, the number of required surgeries for SRS complications (or other related factors) is high in FtM transsexuals (47), as well as MtF ones (48). In this regard, a study showed that transsexual females have a lower mental burden than transsexual males Additionally, demographic and socioeconomic characteristics have strong effects on the QoL of transsexual people. ...
Background: Gender identity disorder (GID) or gender dysphoria is a disorder in which an individual identifies him/herself with the opposite sex. GID following sex reassignment surgery is usually associated with severe distress and several limitations in the personal and social aspects of life as a transgender.
Objectives: The aim of this systematic review and meta-analysis was to evaluate quality of life after sex reassignment surgery in transgender individuals.
Data sources: A search was conducted in English databases, including PubMed, Scopus, PsycINFO, Science Direct, and Google Scholar, as well as Iranian databases including Iran Medex, MagIran, and SID. In addition, the reference lists of the included articles were reviewed without any time limitations. The final literature search was performed on June 12, 2017.
Study selection: All relevant cross-sectional and observational studies were evaluated in this review. The keywords included: “sex”, “gender”, “reassignment surgery”, “reassignment operation”, “sex change”, “sex reversal”, “transpersonal”, “sexual transition", “gender dysphoria”, “transsexual”, “transgender”, “gender identity”, “male-to-female transsexual”, “female-to-male transsexual”, “quality of life”, “QOL”, “quality adjusted”, and “wellbeing”.
Data extraction: After screening 941 articles, sixteen studies were reviewed systematically, six of which were included in the meta-analysis. Comprehensive Meta-Analysis Software Version 2 was used for all meta-analyses.
Results: Quality of life improved after sex reassignment surgery in some dimensions, including bodily pain, emotional role, and mental health in male-to-female (MtF) transsexuals and physical function and physical role in female-to-male (FtM) transsexuals. Physical role, vitality, and social function in MtF transsexuals were not significantly different from the general population. On the other hand, bodily pain, general health, social function, vitality, mental health, and emotional role in FtM transsexuals, as well as physical function and general health in MtF transsexuals, were lower than the general population.
Conclusion: Based on the findings, sex reassignment surgery could improve some dimensions of quality of life, including bodily pain, emotional role, and mental health in MtF transsexuals and physical function and physical role in FtM transsexuals. Nevertheless, further research is necessary in this area.
Keywords: Gender dysphoria; Quality of life; Sex reassignment surgery; Systematic review; Meta-analysis
... The underlying cause of urinary symptoms after SR in transsexual women is not clear. A study 19 postulated that these symptoms may be the result of several factors. Many of these patients have smaller prostates in comparison with the homologous in men because the prostate becomes atrophic after the prolonged use of exogenous estrogen. ...
Vaginoplasty is the most common genital surgery performed for gender affirmation. Annually, there are more than 3000 performed each year. Vaginoplasty is a safe, reliable technique for performing genital transition in transgender female patients. Penile inversion vaginoplasty is the most common technique used today, although there are several other methods of vaginoplasty: penile inversion, visceral interposition, and pelvic peritoneal vaginoplasty. Overall, outcomes are excellent. It is recommended surgeons follow the World Professional Association for Transgender Health (WPATH) guidelines for determining who is a candidate for surgery. There are no absolute contraindications to vaginoplasty, only relative contraindications that include active smoking and morbid obesity. Important but rare complications include flap necrosis, rectal and urethral injuries, rectal fistula, vaginal stenosis, and urethral fistula. When performed correctly in appropriately selected patients by expert surgeons, this is a rewarding operation for both patient and surgeon.
Objective:
To identify the most frequently used protocols for analyzing the myoelectric activity of the pelvic floor muscles during surface electromyography in women aged 18 years or older.
Introduction:
Surface electromyography is normally used in assessment and treatment for research purposes when it is intended to quantitatively measure the electrophysiological behavior of the neuromuscular system. However, although there are internationally standardized, non-invasive assessment protocols for most muscle groups, there is no consensus for pelvic floor muscles, which makes it difficult to standardize in scientific research and clinical applicability.
Inclusion criteria:
Studies that explore registration protocols and filtering parameters of surface electromyographic signals in women aged over 18 years old with or without pelvic floor dysfunction will be considered. Studies encompassing either electromyographic biofeedback as treatment resource only or electroneuromyography (needle electrode) will be excluded.
Methods:
Primary studies published in the last 10 years in MEDLINE, Embase, Scopus, Web of Science, CINAHL, and Cochrane Central databases will be included. The search will encompass descriptors registered in MeSH. The identified articles will be assessed for eligibility by two independent reviewers in three stages: evaluation by title, abstract, and full text. If there is any disagreement, a third reviewer will be consulted. Data will be extracted and organized in standardized spreadsheets. The results will be assigned to categories in order to facilitate the organization of a protocol with the most used parameters for non-invasive assessment of myoelectric activity of pelvic floor muscles.
Background:
Description of an improved technique of metaidoioplasty (clitoris penoid) and presentation of the follow-up of our own patients in comparison to results in the literature.
Patients and methods:
To reduce the complication rate of urethral strictures and urethrocutaneous fistula, the technique of metaidoioplasty was modified: After elongation of clitoris by incision of chorda the urethra-including the clitoral hood-was reconstructed by distally, broadly based flap of labia minora. In a retrospective follow-up study over 4 years, 75 patients completed questionnaires to assess complications and satisfaction/quality of life and urinary symptoms (ICIQ-FLUTS questionnaire). The same questionnaires were completed by 25 patients pre- and 3 months postoperatively.
Results:
In the retrospective study, urethral strictures were detected in 1.4% of patients and urethrocutaneous fistulas in 9.4% of patients, which could be repaired in all cases. Furthermore, 39.5% of patients did not decide for phalloplasty and were satisfied with the appearance of the clitoris penoid in 85% and with their function in 88%. A small proportion of the patients developed urinary symptoms, which were mainly of minor severity and significantly dependent on age. In the prospective study, postoperative-versus preoperative-symptoms of urinary incontinence, nocturia, and obstructive micturition were slightly elevated, but mainly of minor severity.
Conclusions:
The improved technique of metaidoioplasty using distally broadly based labia-minora flaps resulted in high satisfaction with low urethral complication rates.
As more transgender patients undergo gender-affirming genital reconstructive surgery, such as vaginoplasty and phalloplasty, it is imperative for health care providers, including urologists, to understand the new anatomy and most common complications to diagnose and treat patients effectively. Although there have been several modifications to prior techniques as well as development of new techniques over the years, complications are still common after vaginoplasty and phalloplasty. This article focuses on the most common complications as well as the evaluation and management of those complications.
Purpose of review
Analyze the utilization of patient-centered outcomes research (PCOR) methods in the literature containing patient-reported outcome measures (PROMs) for gender affirming surgery (GAS).
Recent findings
Multiple recent systematic reviews have demonstrated that the majority of PROMs used to assess GAS are either ad hoc measures never intended for validation or are neither specific to nor validated for the population or intervention being studied. This review builds on prior works with inclusion of articles related to facial and vocal GAS and presentation of PCOR recommendations and best practices based on review findings.
Summary
A systematic review of records in PubMed and Scopus using search terms related to GAS and PROMs yielded 652 total articles of which 158 were included in the final analysis. Just over half of included articles utilized validated PROMs, though only 38% of those articles utilized a PROM that had been validated in the TGNB population. Thirteen (8.2%) studies detailed the involvement of patients in PROM development as subjects, and only 4 (2.5%) utilized PCOR methods that engaged TGNB individuals as research stakeholders. Utilization of PCOR methods in research evaluating outcomes of GAS is exceedingly rare despite increasing use of PROMs over time. To collect data that are both accurate and meaningful to the TGNB population, PCOR methods must be adopted within this field.
Urinary incontinence in the transgender patient is a common quality of life issue. It is important to understand the impact and overall trends in this population, as well as considering options for treatment. Evaluation includes a thorough history as well as physical examination and determination of cause of incontinence. Treatment options must be individualized to the patient and specific source of incontinence.
Background:
The usefulness of patient-reported outcome measures is emphasized along with the development of patient-centered care. When implementing patient-reported outcome measures, evidence of the instrument's validity, reliability, and responsiveness in the target population is necessary to secure accurate reporting of the patient's experience. The aim of this study was to identify the literature in which structured patient-reported outcome measures have been used to evaluate the results of gender confirmation surgery, and to systematically evaluate the validity of these instruments.
Methods:
A systematic review of the current literature was performed to identify structured patient-reported outcome measures used to evaluate the outcome of gender confirmation surgery. The identified instruments' validity in the transgender population was assessed for adherence to international guidelines for development and validation of health outcomes instruments.
Results:
A total of 110 instruments were identified: 64 ad hoc; six generic; 24 evaluating psychiatric, social, or psychosocial aspects; nine evaluating function but only valid in other patient groups; five ad hoc with some formal development/validation; and two specific for gender dysphoria.
Conclusions:
There is a lack of patient-reported outcome measures that are valid for the transgender population and concurrently sensitive enough to evaluate gender confirmation surgery without the influence of other gender confirming interventions. Basing research on instruments without confirmed validity decreases the validity of the study itself; thus, previous research using patient-reported outcome measures to evaluate gender confirmation surgery can be considered to have a low level of evidence. To obtain valid patient-reported outcome measures, specific for evaluating the results of gender confirmation surgery, development of new instruments or adaptation of existing instruments is needed.
Complications after vaginoplasty surgery for the transgender woman exist. These adverse outcomes can be minor and easily treatable, whereas others are considered major events and require ongoing care. Adverse outcomes can be immediate or remote after surgery and include bleeding, hematoma, infection, delayed wound healing, neovaginal stenosis, visceral injury, and fistula. Patients may also experience pelvic floor disorders after surgery. Providers performing these surgeries and those providers caring for postoperative patients should be aware of the incidence of these complications and the treatment options that exist to manage them.
Introduction
Aim of this study was the evaluation of prevalence of HPV infection and resulting genital dysplasia to assess the necessity and reasonability of pap smears and HPV testing in transgender patients. HPV is the most common sexually transmitted infection and responsible for the majority of genital dysplasias and malignancies. However, few data exist about the prevalence of HPV and dysplasia in transgender people.
Methods
This retrospective data analysis of prospectively collected data includes all patients seen in our specialized outpatient clinic for transgender people. Gynecologic exam, colposcopy, cellular swabs and HPV typing were carried out. Primary endpoint was the prevalence of HPV and genital dysplasias in transgender patients. Secondary endpoints were the subtypes of HPV, demographic data, sexual orientation and co-morbidities in these patients.
Results
We investigated overall 98 patients whereof 53 were transwomen and 45 transmen. Of those, 10.2% had positive HPV tests and 10.2% dysplastic changes in the PAP and one case of invasive anal carcinoma (1.02%).
Comorbidities included recurrent urinary tract infections, psychologic comorbidies and other, possibly hormone replacement related conditions.
Conclusion
The results underline the necessity of a routine gynecological examination including PAP and/or HPV screening and vaccinating, respectively, no matter of sexual orientation or comorbidities. Monitoring the existent anatomy may prevent invasive carcinoma requiring more invasive therapies. Moreover, concomitant pathologies are present and require long-term care of these patients almost all using hormone therapy and carrying several specific risk factors. Transgender-focused guidelines to take into account these peculiarities are needed.
Background:
Vaginoplasty is a gender affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed.
Objectives:
To investigate sexual health after gender-affirming vaginoplasty for TGD patients. Data Sources MEDLINE/PubMed, Embase, Scopus and PsycINFO databases were searched, unrestricted by dates or study design.
Methods:
We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences or aids.
Results:
Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4 - 100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 - 28.6). 64 - 98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia.
Conclusions:
The heterogenous methods of measuring sexual outcomes reflects the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires and inclusive metrics.
Background
In transgender clinics we may be confronted with urological symptoms that may be due to previous operations or to endocrinological reasons.
Objective
Description of the nature of urological problems in transgender people.
Material and methods
Analysis of the current literature and our own data looking at urological problems encountered in counseling of transgender people at the Gynecology Clinic of the Inselspital in Bern.
Results
Urological problems may present as postoperative strictures causing obstruction, incontinence, recurrent urinary tract infections and postmictional dripping. They should be diagnosed and treated according to the cause. Malignant tumors and prolapse are rare conditions.
Conclusion
Patients in transgender clinics should be asked about urogenital complaints that should be analyzed according to the individual situation. Urethral strictures may cause obstruction. Therapy must take the cause of postoperative changes into consideration.
Introduction
Much has been published on the surgical and functional results following Gender Affirming Surgery (‘GAS’) in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking.
Aim
To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine.
Methods
The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS.
Main Outcomes Measure
The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately.
Results
The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing.
Conclusion
The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Müjde Özer, Sahaand Poor Toulabi, Alessandra D. Fisher, et al. ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”. Sex Med 2021;XX:XXXXXX.
Background:
Vaginoplasty is a surgical solution to multiple disorders, including Mayer-Rokitansky-Küster-Hauser syndrome and Male-to-Female gender dysphoria. Using non-vaginal tissues for these reconstructions is associated with many complications and autologous vaginal tissue may not be sufficient. The potential of tissue engineering for vaginoplasty was studied through a systematic bibliography search. Cell type, biomaterial and signalling factors were analyzed by investigating advantages, disadvantages, complications and research quantity.
Search methods:
A systematic search was performed in Medline, EMBASE, Web of Science and Scopus until March 8, 2022. Term combinations for tissue engineering, guided tissue regeneration, regenerative medicine and tissue scaffold were applied, together with vaginoplasty and neovagina. The snowball method on references and a Google Scholar search on the first 200 hits were performed. Original studies on human and/or animal subjects, that met the inclusion (reconstruction of vaginal tissue; tissue engineering method) and no exclusion criteria (not available as full text; written in foreign language; non-original study article; genital surgery other than neovagina reconstruction; vaginal reconstruction with autologous or allogenic tissue without tissue engineering or scaffold) were assessed. The STROBE checklist, Newcastle Ottawa Scale and Gold Standard Publication Checklist were used to evaluate article quality and bias.
Outcomes:
A total of 31 out of 1569 articles were included. Data extraction was based on cell origin and type, biomaterial nature and composition, host specy, number of hosts and controls, neovagina size, replacement fraction and signalling factors. An overview of used tissue engineering methods for neovagina formation was created, showing high variance of cell type, biomaterial and signalling factors and topics were rarely covered multiple times. Autologous vaginal cells and Extracellular Matrix-based biomaterials showed preferential properties and stem cells carry potential. However, quality confirmation of orthotopic cell-seeded Acellular Vaginal Matrix by clinical trials is needed as well as exploration of signalling factors for vaginoplasty.
Impact statement:
Autologous cells prevent complications and compatibility issues like healthy cell destruction, whereas stem cells prevent cross-talk and rejection (but need confirmation testing beyond animal trials). Natural (orthotopic) ECM biomaterials have great preferential properties that encourage future research and signalling factors for vascularization are important for tissue engineering full-size neovagina.
Although sex reassignment surgery (SRS) is an effective treatment method with largely successful results, clinicians occasionally come across persons who regret their decision to undergo SRS. This regret can be inferred from their overt behavior, such as a second social role reversal, or their statements that they regret the steps they have taken. However, their statements and behavior do not always correspond. By means of a semistructured interview, we have extensively interviewed 10 persons who reported feelings of regret or whose overt behavior indicated a significant degree of non-successful postoperative functioning, possibly associated with regret. It appeared that the majority of this group had a (very) late start of cross-dressing and serious psychological problems, which do not merely seem to be a result of their gender dysphoria, before requesting SRS.
Pelvic floor disorders (urinary incontinence, fecal incontinence, and pelvic organ prolapse) affect many women. No national prevalence estimates derived from the same population-based sample exists for multiple pelvic floor disorders in women in the United States.
To provide national prevalence estimates of symptomatic pelvic floor disorders in US women.
A cross-sectional analysis of 1961 nonpregnant women (>or=20 years) who participated in the 2005-2006 National Health and Nutrition Examination Survey, a nationally representative survey of the US noninstitutionalized population. Women were interviewed in their homes and then underwent standardized physical examinations in a mobile examination center. Urinary incontinence (score of >or=3 on a validated incontinence severity index, constituting moderate to severe leakage), fecal incontinence (at least monthly leakage of solid, liquid, or mucous stool), and pelvic organ prolapse (seeing/feeling a bulge in or outside the vagina) symptoms were assessed.
Weighted prevalence estimates of urinary incontinence, fecal incontinence, and pelvic organ prolapse symptoms.
The weighted prevalence of at least 1 pelvic floor disorder was 23.7% (95% confidence interval [CI], 21.2%-26.2%), with 15.7% of women (95% CI, 13.2%-18.2%) experiencing urinary incontinence, 9.0% of women (95% CI, 7.3%-10.7%) experiencing fecal incontinence, and 2.9% of women (95% CI, 2.1%-3.7%) experiencing pelvic organ prolapse. The proportion of women reporting at least 1 disorder increased incrementally with age, ranging from 9.7% (95% CI, 7.8%-11.7%) in women between ages 20 and 39 years to 49.7% (95% CI, 40.3%-59.1%) in those aged 80 years or older (P < .001), and parity (12.8% [95% CI, 9.0%-16.6%], 18.4% [95% CI, 12.9%-23.9%], 24.6% [95% CI, 19.5%-29.8%], and 32.4% [95% CI, 27.8%-37.1%] for 0, 1, 2, and 3 or more deliveries, respectively; P < .001). Overweight and obese women were more likely to report at least 1 pelvic floor disorder than normal weight women (26.3% [95% CI, 21.7%-30.9%], 30.4% [95% CI, 25.8%-35.0%], and 15.1% [95% CI, 11.6%-18.7%], respectively; P < .001). We detected no differences in prevalence by racial/ethnic group.
Pelvic floor disorders affect a substantial proportion of women and increase with age.
To determine the incidence of surgically managed pelvic organ prolapse and urinary incontinence in a population-based cohort, and to describe their clinical characteristics.
Our retrospective cohort study included all patients undergoing surgical treatment for prolapse and incontinence during 1995; all were members of Kaiser Permanente Northwest, which included 149,554 women age 20 or older. A standardized data-collection form was used to review all inpatient and outpatient charts of the 395 women identified. Variables examined included age, ethnicity, height, weight, vaginal parity, smoking history, medical history, and surgical history, including the preoperative evaluation, procedure performed, and details of all prior procedures. Analysis included calculation of age-specific and cumulative incidences and determination of the number of primary operations compared with repeat operations performed for prolapse or incontinence.
The age-specific incidence increased with advancing age. The lifetime risk of undergoing a single operation for prolapse or incontinence by age 80 was 11.1%. Most patients were older, postmenopausal, parous, and overweight. Nearly half were current or former smokers and one-fifth had chronic lung disease. Reoperation was common (29.2% of cases), and the time intervals between repeat procedures decreased with each successive repair.
Pelvic floor dysfunction is a major health issue for older women, as shown by the 11.1% lifetime risk of undergoing a single operation for pelvic organ prolapse and urinary incontinence, as well as the large proportion of reoperations. Our results warrant further epidemiologic research in order to determine the etiology, natural history, and long-term treatment outcomes of these conditions.
Having close social relationships and being married specifically have been reliably associated with health benefits including lower morbidity and mortality.
The purpose of this study was to examine the influence of marital status, relationship quality, and network support on measures of psychological and cardiovascular health.
We examined ambulatory blood pressure (ABP) among 204 married and 99 single males and females (N = 303).
We found that both marital status and marital quality were important. Married individuals had greater satisfaction with life (SWL) and blood pressure dipping than single individuals. High marital quality was associated with lower ABP, lower stress, less depression, and higher SWL. Importantly, contrasting those who are unmarried with those in low-quality marriages, we find that single individuals had lower ABP-suggesting that single individuals fare better than their unhappily married counterparts. Likewise, having a supportive network did not moderate (i.e., buffer) the effects of being single or unhappily married.
Findings indicate being married per se is not universally beneficial, rather, the satisfaction and support associated with such a relationship is important. However, marriage may be distinctive, as evidence further suggests that support from one's network does not compensate for the effect of being single. These results highlight the complexities in understanding the influence of social relationships on long-term health, and they may help clarify the physiological pathways by which such associations exist.
Among older women in East Asia, and Taiwan in particular, there is little research on quality of life and the health care they receive to address the symptoms of menopause. This study evaluated factors which influence quality of life among post middle-age women in Taiwan.
This cross-sectional study recruited 1250 women between 43 and 77 years of age during the year 2002. The factors investigated were demographics, menstruation status, menopausal symptoms, osteoporosis status, and use of hormone replacement therapy (HRT). SF-36 was used to assess the health-related quality of life of these women. Correlation, multiple regression and path analysis were used to test for direct and indirect relationships among the variables.
There are statistical significances between menopause symptoms and quality of life across different age groups. Path analysis shows a direct positive effect of HRT and a direct negative effect of climacteric symptoms on both physical and mental components of quality of life. Age, marital status, education and osteoporosis also have direct and indirect effects, some positive and others negative, on the components of quality of life.
When developing programs to enhance health in post middle-age women, consideration should be given to symptom relief as well as quality of life.
Objective:
To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States.
Methods:
We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures.
Results:
In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars.
Conclusion:
The annual direct costs of operations for pelvic organ prolapse are substantial.
To determine why older people are optimistic, realistic, or pessimistic on self-rated health relative to standard medical health measures, 48 persons older than age 65 were interviewed in an in-depth, semistructured format. Comparisons were made between optimists and poor-health realists, both of whom have serious health problems, to discover the ways in which these groups develop their disparate self-ratings of health. When asked about the meanings they attach to health, respondents variously referred to topics including family history, social comparisons, subjective age, and life expectancy to form their ratings. These results begin to clarify the ways in which different people view similar states of health, building on recent research showing that health pessimists are at an elevated risk of mortality, while health optimists reduce their mortality risk.
Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsex-uals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reas-signment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.
Introduction. Sexual function following genital sexual reassignment surgery (SRS) is an important outcome for many transsexuals, affecting the choice of surgical technique, satisfaction with surgery, and quality of life. However, compared to other outcome measures, little clinical and research attention has been given to sexual functioning following SRS.
Aim. To discuss the potential impact of cross-sex hormone therapy and SRS on sexual function and to summarize the published empirical research on postsurgical sexual functioning in male-to-female (MtF) and female-to-male (FtM) transsexuals.
Methods. Cross-sex hormone therapy and SRS techniques are outlined, the potential roles of cross-sex hormone therapy and SRS on sexual function are discussed, and peer-reviewed literature published in English on postoperative sexual functioning in MtF and FtM transsexuals is reviewed.
Main Outcome Measures. Sexual desire, sexual arousal, and ability to achieve orgasm following SRS.
Results. Contrary to early views, transsexualism does not appear to be associated with a hyposexual condition. In MtF transsexuals, rates of hypoactive sexual desire disorder (HSDD) are similar to those found in the general female population. In FtM transsexuals, sexual desire appears unequivocally to increase following SRS. Studies with MtF transsexuals have revealed not only vasocongestion, but also the secretion of fluid during sexual arousal. Research on sexual arousal in FtM transsexuals is sorely lacking, but at least one study indicates increased arousal following SRS. The most substantial literature on sexual functioning in postoperative transsexuals pertains to orgasm, with most reports indicating moderate to high rates of orgasmic functioning in both MtF and FtM transsexuals.
Conclusions. Based on the available literature, transsexuals appear to have adequate sexual functioning and/or high rates of sexual satisfaction following SRS. Further research is required to understand fully the effects of varying types and dosages of cross-sex hormone therapies and particular SRS techniques on sexual functioning. Klein C, and Gorzalka BB. Sexual functioning in transsexuals following hormone therapy and genital surgery: A review. J Sex Med 2009;6:2922–2939.
In den letzten Jahrzehnten hat sich der kulturelle und soziale Status Transsexueller erheblich verändert. Sie haben Organisationen
gegründet, verfügen über eigene Rechte und können die Leistungen der Krankenversicherungen in Anspruch nehmen. Erheblich verändert
hat sich auch der professionelle Blick. Es werden heute sehr differente Persönlichkeitsstrukturen, Verläufe und sexuelle Präferenzen
beschrieben. Differentialdiagnostisch ist v.a. an homosexuelle und transvestitische Entwicklungen, Psychosen, frühe Persönlichkeitsstörungen,
Adoleszenzkrisen, kulturell induzierte Geschlechtsdysphorien sowie Intersexualismus zu denken. Therapeutisch ist die alte
Konfrontation Psychotherapie vs. Operation weitgehend überwunden. Die Patienten sind heute deutlich jünger. Die Sex-Ratio
nähert sich in Deutschland weltweit erstmalig der Relation 1:1. Die Anzahl erwachsener Transsexueller wird bei uns auf 2000
bis 4000 geschätzt.
In the past decades the cultural and social status of transsexuals has changed considerably. They have established own organizations,
obtained legal rights and acces to health insurance services. The professional point of view has changed as well considerably.
Very different personality structures, developmental courses and sexual preferences are described. As differential diagnoses
homosexual and transvestitic developments, psychoses, early-onset personality disorders, adolescence crises, culturally induced
gender dysphorias, and intersexual disorders have primarily to be considered. In therapy, the old confrontation psychotherapy
vs. surgery has widely been relinguish-ed. Patient’s age is nowadays much lower. Sex ratio in Germany is approaching for the
first time 1:1. So far worldwide a preponderance of biologically male transsexuals is reported. The total number of adult
transsexuals in Germany is estimated 2000–4000.
From 69 transsexual patients (48 men, 21 women) having consulted the Basel University Psychiatric Outpatient-Department between 1970 and 1990, 13 men-to-woman- and 4 woman-to-man-transsexuals could be examined in a follow-up (5–20 years after the operation). The social conditions and the quality of life of the 13 men-to-woman-transsexuals had significantly deteriorated: 9 of the 13 depend on life annuity or on social welfare assistance. The patients live socially very isolated. Eight of them report almost not being able to experience sexual pleasure, 10 suffer from anxieties, depression or addictions. Three regret having demanded the operation and two have passed a second operation for restoration of the original state. The 4 woman-to-man-transsexuals showed slightly better results: 2 of them are fully professionally active and live in constant personal relationships of several years of duration. The 2 others, however, suffer from depression and problems of addiction and give the impression of affective lability. The results lead to the following conclusions: 1. the criteria of indication for the operation of the transsexuals should be observed thoroughly, especially the psychotherapeutic accompaniment before the operation during at least 1 year; 2. the question of emotional stability, of frustration tolerance and of the danger of an outbreak of psychosis are to be examined carefully; 3. the professional and social integration before and after the operation is of central importance.
Little is known about the morphometric properties of the sacrotuberous ligament (ST) and the sacrospinous ligament (SS). The influence of ligaments on pelvic stability and the extent of reconstruction in case of instability are controversially discussed. The ST and the SS of 55 human subjects fixed in alcohol solution and of four fresh cadavers were measured. Both ligaments were defined as geometric figures. The ST was a contorted bifrustum, while the SS was a contorted frustum, both with elliptic planes. In all cases investigated, the ST and the SS fibres were twisted. For men, the ST and the SS had a mean length of 64 and 38 mm. For women, lengths of 70 and 46 mm were measured in the ST and the SS. The ST length, height and cross-sectional area showed gender-specific differences at statistically significant level. The ST and the SS volumes correlated closely, regardless of gender or side. Measurements of fresh ligaments of four unfixed cadavers showed similar results. The data obtained were then used to generate computer-based three-dimensional models of both ligaments, using the Catia® software. Conclusively, the virtually generated ST and SS are suitable models to be included in pelvic fracture simulation, using the finite element method.
Correlates of self-rated health among a randomly selected sample of 1863 Australian-born women 45-55 years of age were examined in two logistic regression analyses: one comparing a self-rated health of worse than one's peers with a self-rated health the same as one's peers; and, one comparing a self-rated health of better than one's peers with a self-rated health the same as one's peers. The final model for worse health was largely a reflection of the physical experience of ill health while that for better health was a more complex construct including not only the absence of illness but also markers of sociodemographic advantage and self-image. The two models had only three variables in common. Notably, the relationship between the outcome measures and one common variable, body mass index, differed markedly. It is suggested that previous analyses of self-rated health have had their power to adequately describe correlates and determinants of health status constrained. By assuming that the various self-rated health states are part of a continuum and employing statistical methods consistent with that assumption, previous studies have been unable to demonstrate the discontinuity among such states. In particular, it is suggested that self-rated health is at least in part a reflection of social role and as there is no basis for assuming that such roles form a continuum as the use of correlation-based analyses imply, then such analyses are inappropriate.
The fascia pelvis parietalis (FPP) or endopelvic fascia is a well-known structure, but few studies described the detailed histological architecture, including the composite fiber directions. We hypothesized a gender-specific fiber architecture corresponding to the functional demand. For the first step to examine this hypothesis, we investigated specimens from 27 adult cadavers (10 males and 17 females) and 11 midterm fetuses (five males and six females) using immunohistochemistry and aldehyde-fuchsin staining. The adult female FPP was a solid, thick monolayered structure that was reinforced by abundant elastic fibers running across the striated muscle fibers, but it contained little or no smooth muscles (SM). In contrast, the male FPP was multilayered with abundant SM. In midterm fetuses, SM originated from the inferior part of the bladder and extended inferiorly along the gender-specific courses. Thus, we found a clear intergender difference in FPP architecture. However, the functional significance remained unknown because the basic architecture was common between nulliparous and multiparous women. Rather than for meeting the likely mechanical demands of pregnancy and vaginal delivery, the intergender difference of the FPP seemed to result from differences in the amount and migration course of bladder-derived SM as well as in hormonal background.
To estimate the prevalence and overlap of overactive bladder (OAB), chronic constipation (CC) and faecal incontinence (FI) among a general population sample of adults in the USA.
A cross-sectional internet-based survey of randomly selected panel members who were ≥ 40 years of age was conducted. Participants reported how often they experienced symptoms of OAB, CC and FI using Likert scales and modified Rome III criteria. Analyses were conducted to examine the overall prevalence of OAB, CC and FI in men and women separately and to characterize the extent of overlap between these conditions in participants with OAB vs those without OAB, and those participants with continent vs incontinent OAB.
The response rate for the survey was 62.2% and the final sample (N= 2000) included 927 men and 1073 women. The overall prevalence of OAB [defined as a response of ≥ 'sometimes' to urinary urgency (i.e. 'sometimes' or more often) or 'yes' to urinary urgency incontinence (UUI)] was 26.1% in men and 41.2% in women. The overall prevalence of CC was significantly lower in men than in women (15.3 vs 26.3%), but both men and women with OAB were significantly more likely to report CC (22.3 and 35.9% vs 5.7 and 6.7%, respectively, P < 0.0001). The overall prevalence of FI reported 'rarely' or more was 16.7% of men and 21.9% of women. Men and women with OAB were significantly more likely to report FI than those without OAB. FI was also more common in participants with incontinent OAB than in those with continent OAB. Logistic regressions controlling for demographic factors and comorbid conditions suggest that OAB status is a very strong predictor of CC, FI and overlapping CC and FI (odds ratios, range 3.55-7.96).
Chronic constipation, FI and overlapping CC and faecal incontinence occur more frequently in patients with OAB and should be considered when evaluating and treating patients with OAB. These findings suggest a shared pathophysiology among these conditions. Additional study is needed to determine if successful treatment of one or more of these conditions is accompanied by commensurate improvement in symptoms referable to the other organ system.
Sexual desire depends on the balance between biologic, psychological, and cultural values. Therefore, conceptualizations of female sexual desire difficulties should consider the interrelated role of those factors.
The aim of this study was to test a conceptual model regarding factors often implicated on female sexual desire, in order to understand the way those factors interact in sexual interest. Moreover, we intended to evaluate the mediation role of cognitive-emotional factors between sexual desire and other dimensions such as age, medical problems, psychopathology, or dyadic adjustment.
Two hundred and thirty-seven women from the general population participated in the study. We evaluated psychopathology, dysfunctional sexual beliefs, automatic thoughts and emotions during sexual activity, dyadic adjustment, and presence of medical problems.
Psychopathology measured by the Brief Symptom Inventory, dysfunctional sexual beliefs measured by the Sexual Dysfunctional Beliefs Questionnaire, thoughts and emotions in sexual context measured by the Sexual Modes Questionnaire, dyadic adjustment measured by the Dyadic Adjustment Scale, medical condition measured by the Medical History Formulation, and sexual desire measured by the Sexual Desire subscale of the Female Sexual Function Index.
Results from the proposed conceptual model suggest that cognitive factors (mainly automatic thoughts during sexual activity) were the best predictors of sexual desire. In a more specific way, age, failure/disengagement thoughts, and lack of erotic thoughts during sexual activity, showed a significant direct effect on reduced sexual desire. Furthermore, sexual conservatism beliefs, and medical factors showed indirect effects, acting on sexual desire via the presence of lack of erotic thoughts, and failure/disengagement sexual thoughts, respectively.
Results from this integrative approach support the need to include cognitive dimensions in the assessment and treatment of sexual desire problems, considering their implication as vulnerability or resilient factors regarding deficient sexual interest in women.
A method is presented to create a neovagina in the male transsexual, using the penile skin as an island flap for the vaginal lining. The labia are shaped with scrotal skin, using two Z-plasties; a small bud of corpus cavernosum covered by penile skin substitutes for a clitoris.
Male-to-female (M-F) transsexuals differ consistently from female-to-male (F-M) transsexuals in their sociodemographic characteristics, cross-gender and sexual history and the degree to which personality disorder is concomitant to their transsexuality. As a group, female-to-male transsexuals are more homogeneous. Both groups are impaired in their mental functioning, but the male-to-female population is more mentally disordered. In a comparison between Dutch transsexuals and their Belgian counterparts, the latter were shown to have more mental problems.
Our experience in reconstructive surgery of the penis in 136 cases is reported. The postoperative complication rate was 13.24 percent. Five methods were used: the radial forearm free flap, the superficial inferior epigastric artery flap, the superficial circumflex iliac artery flap, the anterolateral thigh flap, and the combined cutaneous flap. The choice of the method had to be made depending on the patient's condition and prediction of the operative results. The penis not only should have a good appearance with normal size but also should have good sensation and function. The keys to success of this operation are considered to be correct preoperative planning, careful manipulation, and excellent anastomoses.
The prevalence of transsexualism in the Netherlands was estimated by counting all the subjects who were diagnosed as transsexuals by psychiatrists or psychologists and were subsequently hormonally treated and generally underwent sex-reassignment surgery. At the end of 1990, 713 Dutch-born transsexuals received treatment (507 men, 206 women). This amounts to a prevalence of 1:11,900 for male-to-female transsexualism and 1:30,400 for female-to-male transsexualism (population age 15 and above in both groups). The sex ratio was about 2.5 men to 1 woman. The most important reason for this relatively high prevalence seems to be the benevolent climate for the treatment of transsexualism in the Netherlands.
This article presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction. An objective site-specific system for describing, quantitating, and staging pelvic support in women is included. It has been developed to enhance both clinical and academic communication regarding individual patients and populations of patients. Clinicians and researchers caring for women with pelvic organ prolapse and pelvic floor dysfunction are encouraged to learn and use the system.
To develop a questionnaire that is sensitive to changes in the symptomatology of the female lower urinary tract, particularly urinary incontinence, providing an instrument that can characterize symptom severity, impact on quality of life and evaluate treatment outcome.
Items covering as wide a range of urinary symptoms as possible were devised after consultation with clinicians and a health scientist, a literature review and discussion with patients. Additional items assessed the degree of 'bother' that symptoms were causing. Eighty-five women with clinical symptoms attending for urodynamic assessment and 20 women with none were asked to self-complete the questionnaire. The instrument's validity was assessed by interviewing patients and measuring levels of missing data, comparing symptom scores between clinical and non-clinical populations and comparison with frequency/volume charts and data from pad tests. The instrument's reliability was assessed by measuring both internal consistency and stability, using a 2-week test-retest analysis.
The questionnaire was completed by the patients with a mean of only 2% of items missing; most questions were easily understood. Construct validity was good, with the instrument easily differentiating clinical and non-clinical populations. Criterion validity, as tested against frequency/volume charts and pad-test data, was acceptable, with Kappa coefficients of 0.29-0.79 for frequency/volume data and Spearman rank correlations of 0.50-0.97 and 0.31-0.67 for frequency/volume and pad-test data, respectively. The reliability of the instrument was good; a Cronbach's alpha of 0.78 indicated that the symptom questions had high internal consistency, while stability was excellent, with 78% of symptoms and problems answered identically on two occasions, and Spearman rank correlations of 0.86 and 0.90, respectively.
The instrument has good psychometric validity and reliability. The stability demonstrated at baseline and the ability to differentiate clearly between community and clinical populations suggest that it should be ideal for measuring changes following therapeutic intervention. The addition of life-impact items and a 'bother' factor may provide the opportunity to identify those women who wish treatment for their symptoms; this dimension requires further exploration.
In light of possible emulation of the German Transsexuals' Act (TSG) in discussions taking place on future legislation in other states, on the 10th anniversary of the German TSG, we review the application of this law, as well as epidemiological data arising from its use. From 1981 to 1990, 1422 judicial decisions were rendered in Germany on this basis: 683 of them related to the so-called "small solution" (change of first name), and 733 involved what is termed the "major solution" (legal change of sex status). The frequency of transsexual applications over these 10 years lay between 2.1 and 2.4 per 100,000 German adult population. The average age was 33. Only 3.6% and 10.9% of the small and major applications, respectively, were rejected by courts. The sex ratio was 2.3:1 in favor of male-to-female transsexuals. Data revealed no significant trend over the years among the prevailing practices of adjudication, but evidence does exist that the German courts apply the law differently on a regional basis. Over the 10-year period, only six persons requested to have their names changed back again and only one to be reassigned to the former legal sex classification. Those who change their first names in the sense of a tentative accustomizing process waited an average of 2 years before changing their gender. Between 20 and 30% apparently went no further than the so-called "small solution."
A long-term follow up of 136 patients operated on for sex reassignment was done to evaluate the surgical outcome. Social and psychological adjustments were also investigated by a questionnaire in 90 of these 136 patients. Optimal results of the operation are essential for a successful outcome. Personal and social instability before operation, unsuitable body build, and age over 30 years at operation correlated with unsatisfactory results. Adequate family and social support is important for postoperative functioning. Sex reassignment had no influence on the person's ability to work.
In the past decades the cultural and social status of transsexuals has changed considerably. They have established their own organizations, obtained legal rights and access to health insurance services. The professional point of view has changed as well considerably. Very different personality structures, developmental courses and sexual preferences are described. As differential diagnoses homosexual and transvestitic developments, psychoses, early-onset personality disorders, adolescence crises, culturally induced gender dysphorias, and intersexual disorders have primarily to be considered. In therapy, the old confrontation psychotherapy vs. surgery has widely been relinquished. Patient's age is nowadays much lower. Sex ratio in Germany is approaching for the first time 1:1. So far worldwide a preponderance of biologically male transsexuals is reported. The total number of adult transsexuals in Germany is estimated 2000-4000.
Our objective was to study the prevalence of genital prolapse and possible related factors in a general population of women 20 to 59 years of age.
Of 641 eligible women in a primary health care district, 487 (76%) answered a questionnaire and accepted an invitation to a gynecologic health examination.
The prevalence of any degree of prolapse was 30.8%. Only 2% of all women had a prolapse that reached the introitus. In a set of multivariate analyses, age (P <.0001), parity (P <.0001), and pelvic floor muscle strength (P <.01)-and among parous women, the maximum birth weight (P <.01)-were significantly and independently associated with presence of prolapse, whereas the woman's weight and sustained hysterectomy were not.
Signs of genital prolapse are frequently found in the female general population but are seldom symptomatic. Of factors associated with genital prolapse found in this study, pelvic floor muscle strength appears to be the only one that could be affected.
Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.
To describe the techniques and outcome of genital and urethral reconstructive surgery during gender conversion as part of the treatment of transsexuals.
From 1992 to 1999, 82 patients were surgically converted after previous sexual and hormonal therapy. Using the male genital tissue to create new female genitalia, and vice versa, 30 male and 52 female transsexuals were converted. For male-to-female transsexuals, the technique of penile skin inversion was used 29 times and sigmoidocolpoplasty five times (in one patient primarily and in four patients to correct inadequate neovaginal size after penile skin inversion). In female-to-male transsexuals, 28 meta-idoioplasties and seven neophalloplasties were performed using the groin skin-flap technique, with 42 breast reductions also included as a part of the therapy.
Surgical gender reassignment of the male transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm. Depending on the technique used in the reverse conversion, the patient maintained the ability to attain orgasm, and in many cases had a satisfactory appearance of the neopenis, with the potential to void while standing.
The morphological proportions of each patient vary, and the different shapes and sizes of the tissues can be used for plastic operations. Thus the modelling of each individual genital in transsexuals can be considered 'original'.
To report experience of a new surgical technique in male-to-female transsexual patients, the complications, and the functional and psychosocial long-term results.
From April 1995 to July 2000, 66 male patients underwent gender-transforming surgery at our institution and were registered prospectively. The operation should result in a normal appearing introitus, a vaginoplasty allowing for sexual intercourse and a sensitive clitoris. This was achieved by preserving the neurovascular bundle. The glans was transformed into a clitoris, the phallic cylinder used as a vagina and labia were formed from the scrotal folds.
Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft. A long-term follow-up questionnaire about the functional and psychosocial aspects was completed by 31 patients. More than 90% of the patients were satisfied with the cosmetic result and capacity for orgasm; 58% reported having sexual intercourse.
Male-to-female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender-transforming surgery.
To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States.
We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures.
In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars.
The annual direct costs of operations for pelvic organ prolapse are substantial.
Vaginal palpation is commonly used in clinical practice to teach and evaluate pelvic floor muscle strength, and several grading systems have been developed. The aim of the present study was to test inter-rater reproducibility of the modified Oxford grading system and compare results from vaginal palpation with squeeze pressure measurement.
Twenty female physical therapy students, mean age 25.1 years (range 21-38) participated in the study. Two experienced physical therapists conducted the palpation test in random order. Muscle strength was classified according to a 6-point scale (modified Oxford grading system). Results from the palpation test were compared with measurement of vaginal squeeze pressure using a vaginal balloon connected to a fiberoptic microtransducer (Camtech AS, Sandvika, Norway). To ensure validity of pressure measurement only contractions with simultaneous observation of inward movement of the perineum were registered.
The inter-rater reliability for vaginal palpation was 0.70 measured by Spearman's rho (p<0.01). Cohen's Kappa was kappa=0.37 (SEM 0.16). There was agreement between the physical therapists in nine subjects (45%). In all but one subject the disagreement was one category. Mean maximal strength for the group was 19.7 cm H2O (95% CI: 16.5-22.9). There were no differences between weak, moderate, good and strong muscle contraction classified by palpation test when comparing results from the vaginal squeeze pressure (p=0.66).
Vaginal palpation is mandatory when teaching correct pelvic floor muscle contraction. However, the present results indicate that the method is not reproducible, sensitive and valid to measure PFM strength for scientific purposes.
To develop a simple but sensitive instrument to evaluate and document symptoms of both bowel and urinary dysfunction in women.
A 22-item questionnaire covering a range of bowel and urinary symptoms was developed and underwent rigorous psychometric testing.
The gynaecology departments of three hospitals, a urogynaecology clinic, a functional bowel clinic and a general practice.
Six hundred and thirty women, comprising four groups: 1. women awaiting hysterectomy (n = 379), 2. women following hysterectomy (n = 45), 3. women referred with functional bowel and/or urinary symptoms (n = 65), 4. asymptomatic controls (n = 141).
The content, construct and criterion validity, internal consistency, reliability and responsiveness of the questionnaire were measured. RESULTS Peer and patient reports and missing data patterns supported face and content validity. Factor analysis showed a clinically relevant four-factor structure with low content replication able to distinguish between patient groups, indicating good internal structure. Comparison with clinical, anorectal physiological, videoproctographic, transit time and urodynamic test results provide provisional indication of criterion validity. Key domain question analysis and Cronbach's alphas showed internal consistency. Kappa values demonstrated good test-retest reliability and key question correlation over time proved responsiveness.
Our findings support the suitability, clinical validity, reliability and responsiveness of a simple questionnaire, which is sensitive to the constraints of clinical practice. The authors recommend its use in health care evaluation research assessing the effects of pelvic surgery and as a useful tool in comparing treatment efficacy.
We present a patient who underwent male-to-female reassignment, and then developed squamous cell carcinoma during a complicated long-term follow-up. In very rare cases, squamous cell carcinoma may be considered in the differential diagnosis of sustained ulceration in neovaginas constructed by inverting the penile skin in male-to-female reassignments, in particular because clinical examination may be hampered by contractile scar formation of the neovaginal canal. Despite the lack of statistical evidence, it may be assumed that the heterotopic penile skin is at an increased risk of developing HPV-induced squamous cell carcinoma, especially if, over the years, there is a personal history of venereal warts.
This study examined factors associated with satisfaction or regret following sex reassignment surgery (SRS) in 232 male-to-female transsexuals operated on between 1994 and 2000 by one surgeon using a consistent technique. Participants, all of whom were at least 1-year postoperative, completed a written questionnaire concerning their experiences and attitudes. Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret. Dissatisfaction was most strongly associated with unsatisfactory physical and functional results of surgery. Most indicators of transsexual typology, such as age at surgery, previous marriage or parenthood, and sexual orientation, were not significantly associated with subjective outcomes. Compliance with minimum eligibility requirements for SRS specified by the Harry Benjamin International Gender Dysphoria Association was not associated with more favorable subjective outcomes. The physical results of SRS may be more important than preoperative factors such as transsexual typology or compliance with established treatment regimens in predicting postoperative satisfaction or regret.
Penectomy, bilateral orchiectomy, and penoscrotal flap vaginoplasty are procedures that increase the psychosocial well-being and enhance body acceptance of male-to-female transsexuals. The incidence of neovaginal prolapse is not known but is believed to be relatively rare. We report 2 cases of neovaginal prolapse that were successfully treated with abdominal sacral colpopexy at our institution.
The purpose of this study was to evaluate the psychometric properties of and validate the German-language version of the King's Health Questionnaire (KHQ) in women with stress urinary incontinence (SUI).
A total of 145 women treated for stress incontinence with surgery or physiotherapy completed the the KHQ and the SF-36 before and after treatment. Psychometric analyses of the quality of life (QoL) instruments determined the reliability (Cronbach's alpha), internal and external validity, and responsiveness of the KHQ subscales.
The KHQ showed good internal consistency, content validity, and criterion validity as measured by correlation with scores on the SF-36. Cronbach's alpha coefficient ranged from 0.76 to 0.86, indicating a high internal consistency of the subscales. Concerning criterion validity, correlations between the KHQ subscales and the SF-36 were low to moderate. The highest correlation was found between the general health perception subscales of both questionnaires.
The results indicate good psychometric properties for the German-language KHQ.
To investigate the effects of sex reassignment surgery (SRS) on lower urinary tract function.
A questionnaire concerning voiding habits and lower urinary tract symptoms after sex reassignment surgery, was given to 24 female-to-male transsexuals (FTM) and 31 male-to-female transsexuals (MTF), who respectively underwent phalloplasty and vaginoplasty. For this study only Dutch speaking patients were selected. Also, uro-flowmetry data from 92 FTM transsexuals were reviewed.
In general, no change in voiding patterns was observed. Post-void dribbling was reported by 79% of the FTM transsexuals, and 16% of the MTF group reported some form of incontinence. The uro-flowmetry examination showed a mean, non-significant decrease of 2 ml/s in Q(max) in FTM patients.
SRS can cause minor changes in urinary habits. Even if they do not result in patients seeking medical help, transsexuals should be warned about these eventual discomforts pre-operatively.
The purpose of this study was to describe the distribution of pelvic organ support in a gynecologic clinic population to define the clinical disease state of pelvic organ prolapse and to analyze its epidemiologic condition.
This was a multicenter observational study. Subjects who were seen at outpatient gynecology clinics who required an annual gynecologic examination underwent a pelvic organ prolapse quantification examination and completed a prolapse symptom questionnaire. Receiver operator characteristic curves were used to define pelvic organ prolapse with the use of symptoms and pelvic organ prolapse quantification examination measures. Standard age-adjusted univariate and multivariate logistic regression analysis were used to evaluate various relationships.
The population consisted of 1004 women who were aged 18 to 83 years. The prevalence of pelvic organ prolapse quantification stages was 24% (stage 0), 38% (stage 1), 35% (stage 2), and 2% (stage 3). The definition of pelvic organ prolapse that was determined by the receiver operator characteristic curve was the leading edge of their vaginal wall that was -0.5 cm above the hymenal remnants. Multivariate analysis revealed age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus as risk factors for pelvic organ prolapse, as defined in this population.
The results from this population suggest that there is a bell-shaped distribution of pelvic organ support in a gynecologic clinic population. Advancing age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus have the strongest correlations with prolapse.
Surgery for Crohn's disease (CD) is associated with a high recurrence rate and quality of life (QOL) in these patients is controversial. The aim of this study was to assess QOL in patients after laparoscopic and open surgery for CD by two different validated instruments, a generic nonspecific score and a specific gastrointestinal QOL index.
Patients with CD who underwent elective laparoscopic or open ileocaecal resection with primary anastomosis between 1992 and 2000 were followed for recurrence and surgery-related complications. QOL was assessed by the SF-36 Health Survey containing a mental (MCS) and a physical (PCS) component summary score and by the Gastrointestinal Quality of Life Index (GIQLI) developed by Eypasch.
Thirty-seven patients with a mean age of 48.8 +/- 18.4 years including 23 females and 14 males were evaluated at a mean follow-up of 42.6 +/-25.8 months (minimum of 8 months). Twenty-one (57%) patients underwent laparoscopic resection and 16 (43%) open surgery. Both groups were well matched for age, gender, ASA class and body mass index. Fourteen (38%) patients developed recurrent disease and 3 (8%) had postoperative incisional hernias. Overall, QOL scores were 103 +/- 26.8 for the GIQLI, 47.2 +/- 11.8 for the PCS, and 49.2 +/- 11.5 for the MCS. The GIQLI correlated well with the SF36, correlation coefficient = 0.68 for GIQLI vs PCS (95% CI, 0.41,0.95) and 0.67 for GIQLI vs MCS (95%CI, 0.39, 0.95), respectively. When compared to the general US population, mean GIQLI scores (-13.8, P = 0.002) and mean PCS scores (-4.7, P = 0.001) were significantly lower in these patients than in healthy individuals. In a multivariate analysis of impact factors on QOL, recurrence within the follow-up period was the single significant determinant reducing the PCS (-35.1, P = 0.026) and the GIQLI (-36.1, P = 0.018).
QOL is significantly reduced in patients with CD at long-term follow-up after both laparoscopic and open surgery. Recurrence is the only factor adversely affecting QOL of CD patients in remission irrespective of the operative technique applied.
To assess the relationship and location of vaginal prolapse severity to symptoms and quality of life.
A prospective observational study.
Urogynaecology Unit, Imperial College, St Mary's Hospital, London.
Women with and without symptoms of vaginal prolapse.
All women completed a validated Prolapse Quality of Life (P-QOL) questionnaire. This included a urinary, bowel and sexual symptom questionnaire. All women were examined using the Pelvic Organ Prolapse Quantification system (POP-Q). POP-Q scores in those with and without prolapse symptoms were compared. Urinary and bowel symptoms and sexual function were compared and related to prolapse severity and location.
POP-Q scores, P-QOL scores, urinary and bowel symptoms and sexual function.
Three hundred and fifty-five women were recruited-233 symptomatic and 122 asymptomatic of prolapse. The median P-QOL domain scores ranged between 42-100 in symptomatic women and 0-25 in those who were asymptomatic. The stage of prolapse was significantly higher in those symptomatic of prolapse (P < 0.001) except for perineal body (PB) measurement. Urinary symptoms were not correlated with uterovaginal prolapse severity whereas bowel symptoms were strongly associated with posterior vaginal wall prolapse. Cervical descent was found to have a relationship with sexual dysfunction symptoms.
Women who present with symptoms specific to pelvic organ prolapse demonstrate greater degrees of pelvic relaxation than women who present without symptoms. Prolapse severity and quality of life scores are significantly different in those women symptomatic of prolapse. There was a stronger relationship between posterior prolapse and bowel symptoms than anterior prolapse and urinary symptoms. Sexual dysfunction was related to cervical descent.
Transsexualism occurs with an estimated prevalence of 2.4:100,000 male-to-female (MTF) and 1:100,000 female-to-male (FTM) transsexuals. As sex reassignment surgery involves surgery of the urethra and transsexuals are substituted life-long with the cross gender hormones there could possibly arise micturition disorders. Aim of the study was to determine if transsexuals have an increased risk of micturition disorders and if so which.
Between January and July 2003 we examined 25 transsexuals whereof 18 were MTF and 7 were FTM transsexuals using King's Health Questionnaire, visual analogue scale for patient's well being, perineal and transabdominal ultrasound, urine dipstick and uroflow measurement.
17 out of 25 patients considered themselves very happy. In MTF transsexuals, a diverted stream, overactive bladder and stress urinary incontinence was a common problem. Prostate volume was small with 20 g and palpation did not confirm and solid or suspicious lesions. None of the patients had significant residual urine but MTF transsexuals had a reduced urinary flow. We could not detect a current urinary tract infections in any of the patients.
Transsexuals have an increased risk for the development of micturition disorders including stress urinary incontinence and overactive bladder compared to age-matched control groups and should be counselled preoperatively. Reasons for the development of incontinence might be surgery including pudendal nerve damage, hormonal reasons and ageing.
A wide range of symptoms are commonly ascribed to pelvic organ prolapse including pain, awareness of lump, bowel, bladder and sexual dysfunction. The aim of this work was to develop and validate an instrument to quantify symptoms related to pelvic organ prolapse. Consultation with symptomatic women and specialists in coloproctology, urology, gynaecology and sexual health resulted in a questionnaire with 25 questions. In total, 203 women participated in a psychometric testing of this instrument, 152 cases with prolapse and 51 controls without. The content validity, criterion validity, reliability and responsiveness of the questionnaire were evaluated. The questionnaire proved a reliable and valid instrument for the assessment of symptoms related to uterovaginal prolapse. It is also sensitive to change.
To report our experiences of vaginal sacrospinous ligament fixation after vaginoplasty in male transsexual patients with the aim of preventing its postoperative prolapse.
From August 1997 through November 2005, a total of 62 male transsexual patients (mean age 26 years, range 18 to 58) underwent sacrospinous ligament fixation for neovaginal prolapse during male-to-female sex reassignment surgery. The neovagina was created from a penile skin tube flap combined with a urethral flap. A deep and wide perineal cavity between the urethra, bladder, and rectum was created by dissection of the tendineous center and rectourethral muscle. The right pararectal space was opened by penetrating the right pararectal fascia (rectal pillar) and right ischial spine was palpated. Using the ischial spine as a prominent landmark, the sacrospinous ligament was palpated. Long-handled Deschamps ligature was used to pierce the ligament medially to the ischial spine. Vaginopexy to the sacrospinous ligament was performed, and the neovagina was placed deep in the perineal cavity.
The median follow-up was 32 months (range 7 to 102). Sacrospinous ligament fixation was successfully performed in all patients. The mean vaginal length was 10.7 cm (range 9.5 to 16). Of the 62 patients, 42 (76%) were able to have normal sexual intercourse. The appearance of the neovagina was aesthetically acceptable in 52 patients. In 3 cases, a minor bulge of the anterior vaginal wall was easily resolved by simple excision.
Vaginal sacrospinous fixation is feasible in male transsexuals for neovaginal prolapse prevention. However, extensive experience with male pelvic surgery is required to avoid possible complications.
Health-related quality of life (HR-QOL) assessment in esophageal cancer is increasingly performed. However, the association of baseline HR-QOL in predicting outcome is unclear. This study aimed to assess the impact of HR-QOL scores at diagnosis with major morbidity, mortality, failure to progress to surgery, recurrence within 1 year, and survival in patients with localized esophageal cancer. The European Organization for Research and Treatment of Cancer's quality of life questionnaire was completed at diagnosis. Univariate and multivariate logistic regression were used to investigate the relationship between baseline HR-QOL and outcomes adjusting for confounding variables. A total of 185 patients with localized esophageal cancer were included, 89 undergoing multimodal therapy and 96 surgery alone. Global QOL scores were significantly associated with in-hospital mortality (P = 0.020) but not with major morbidity (P = 0.709) or 1-year survival (P = 0.247). Symptoms of fatigue and dyspnea at baseline were significantly (P < 0.05) associated with major morbidity, in-hospital mortality, and survival in univariate analysis. After adjusting for known confounding variables in multivariate analysis, only worse dyspnea score remained predictive of in-hospital mortality and a worse fatigue score remained predictive of 1-year survival. HR-QOL was of no benefit in predicting survival in multivariate analysis that identified pathological nodal status as the most significant factor. HR-QOL questionnaires may be helpful in preoperative assessment of risk. It is possible that patients with unrecognized micrometastatic disease at the time of surgery may report worse systemic symptoms at diagnosis, in particular fatigue and dyspnea, and these and global QOL scores may also identify poorer reserves that may increase in-hospital morbidity and mortality postoperatively.
The Bristol lower urinary tract symptoms questionnaire: development and psychometric testing
- S Jackson
- J Donovan
- S Brooks
- S Eckford
- L Swithinbank
- P Abrams
Jackson S, Donovan J, Brooks S, Eckford S,
Swithinbank L, Abrams P. The Bristol lower urinary
tract symptoms questionnaire: development and psychometric testing. Br J Urol 1996;77:805-12.