The objective of this literature review is to update the recommendations for clinical practice about the diagnosis of pelvic inflammatory disease (PID), microbiologic diagnosis excluded. An adnexal ...pain or cervical motion tenderness are the signs that allow a positive diagnosis of PID (LE2). Associated signs (fever, leucorrhoea, metrorrhagia) reinforce clinical diagnosis (LE2). In a woman consulting for symptoms compatible with PID, a pelvic clinical examination is recommended (grade B). In cases of suspected PID, hyperleukocytosis associated with a high C-reactive protein suggests a complicated PID or a differential diagnosis such as acute appendicitis (LE3). The absence of hyperleukocytosis or normal CRP does not rule out the diagnosis of PID (LE1). When PID is suspected, a blood test with a blood count and a CRP test is recommended (grade C). Pelvic ultrasound scan does not contribute to the positive diagnosis of uncomplicated PID because it is insensitive and unspecific (LE3). However, ultrasound scan is recommended to look for signs of complicated PID (polymorphic collection) or differential diagnosis (grade C). Waiting for an ultrasound scan to be performed should not delay the start-up of antibiotic therapy. In case of diagnostic uncertainty, an abdominal-pelvic CT scan with contrast injection is useful for differential diagnosis of urinary, digestive or gynaecological origin (LE2). Laparoscopy is not recommended for the unique purpose of the positive diagnosis of PID (grade B).
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK, ZRSKP
Objective
Our aim was to study risk factors associated with the prevalence, incidence and remission of urinary incontinence (UI) between 4 and 24 months postpartum.
Design
Longitudinal study (EDEN ...cohort).
Setting
Two French university hospitals.
Population
1643 women completed the questionnaire at 4 months and 1409 at 24 months, including 1354 who completed it both times.
Methods
Multivariate analyses identified risk factors for UI prevalence at 24 months postpartum, persistent UI versus remission, de novo UI versus continence, de novo UI versus persistent UI, and changes in IU severity between 4 and 24 months postpartum.
Main outcome measures
Postnatal UI and Sandvik UI severity score.
Results
UI prevalence was 20.7% (340/1643) at 4 months and 19.9% (280/1409) at 24 months. Significant factors associated with UI at 24 months were older age OR = 1.07/year (95%CI 1.04–1.11), BMI 2.35 (1.44–3.85) ≥30 versus <25 kg/m², higher parity 1.77 (1.14–2.76) ≥3 versus 1, breastfeeding 1.54 (1.08–2.19) ≥3 versus < 3 months, pregnant at follow up 3.44 (2.25–5.26), and caesarean delivery 0.62 (0.40–0.97) versus vaginal OR, odds ratio (CI, confidence interval). The likelihood of UI remission at 24 months was 51.9% (149/287). Caesarean delivery was associated with increased likelihood of UI remission 0.43 (0.19–0.97). The risk of de novo UI at 24 months was 12.5% (135/1067) and was associated with a new pregnancy 3.63 (2.13–6.20).
Conclusions
Between 4 and 24 months postpartum UI, remission occurred in half of the cases. These postnatal UI changes were essentially related to mode of delivery and subsequent pregnancy.
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Postnatal urinary incontinence progression is mostly related with mode of delivery and subsequent pregnancy.
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Postnatal urinary incontinence progression is mostly related with mode of delivery and subsequent pregnancy.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objective
Urinary incontinence (UI) is often considered to be an age‐related disease that develops gradually as women grow older. Much remains to be learnt about factors that promote its incidence or ...its remission. Our objective was to assess its incidence and risk factors.
Design
Longitudinal cohort study.
Setting
French GAZEL cohort.
Population
A cohort of 4127 middle‐aged women (aged 47–52 years at baseline) over an 18‐year period (1990–2008).
Methods
UI was defined as ‘difficulty retaining urine’. The question was asked at baseline and repeated every 3 years over an 18‐year period. Two groups (UI incidence and remission) were analysed according to status at baseline (continent or incontinent). A multivariable analysis (Cox model) was used to estimate the risk factors for UI incidence and remission.
Main outcome measures
Annual incidence and remission rates and risk factors for UI incidence and remission.
Results
The annual incidence and remission rates for UI were 3.3% and 6.2%, respectively. High educational level (hazard ratio HR = 1.28; 95% confidence interval 95% CI = 1.05–1.55), parity, i.e. at least one baby versus no baby (HR = 1.64; 95% CI = 1.19–2.27), menopause (HR = 5.44; 95% CI = 4.47–6.63), weight gain, i.e. for each kilogram change in weight (HR = 1.00; 95% CI = 1.00–1.02), onset of depressive symptoms (HR = 1.31; 95% CI = 1.09–1.57) and impairment in health‐related quality of life incidence (social isolation dimension HR = 1.29; 95% CI = 1.04–1.60 and energy dimension HR = 1.41; 95% CI = 1.17–1.70) were associated with an increased probability of UI. The factors associated with persistent UI were age (HR = 0.58; 95% CI = 0.55–0.61), weight gain (HR = 0.99; 95% CI = 0.98–0.99) and transition to menopausal status (HR = 1.54; 95% CI = 1.19–1.99).
Conclusions
Our study suggests that, in our population of middle‐aged women, age, menopause, weight gain, onset of depression and impaired health‐related quality of life may promote UI.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter injuries (OASIS) and postnatal ...pelvic floor symptoms.
These guidelines were developed in accordance with the methods prescribed by the French Health Authority (HAS).
A prenatal clinical examination of the perineum is recommended for women with a history of Crohn's disease, OASIS, genital mutilation, or perianal lesions (professional consensus). Just after delivery, a perineal examination is recommended to check for OASIS (Grade B); if there is doubt about the diagnosis, a second opinion should be requested (Grade C). In case of OASIS, the injuries (including their severity) and the technique for their repair should be described in detail (Grade C). Perineal massage during pregnancy must be encouraged among women who want it (Grade B). No intervention conducted before the start of the active phase of the second stage of labour has been shown to be effective in reducing the risk of perineal injury. The crowning of the baby's head should be manually controlled and the posterior perineum manually supported to reduce the risk of OASIS (Grade C). The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). In instrumental deliveries, episiotomy may be indicated to avoid OASIS (Grade C). When an episiotomy is performed, a mediolateral incision is recommended (Grade B). The indication for episiotomy should be explained to the woman, and she should consent before its performance. Advising women to have a caesarean delivery for primary prevention of postnatal urinary or anal incontinence is not recommended (Grade B). During pregnancy and again in the labour room, obstetrics professionals should focus on the woman's expectations and inform her about the modes of delivery.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPUK, ZAGLJ, ZRSKP
Objective
To compare the effectiveness and safety of laparoscopic sacropexy (LS) and transvaginal mesh (TVM) at 4 years.
Design
Extended follow up of a randomised trial.
Setting
Eleven centres.
...Population
Women with cystocele stage ≥2 (pelvic organ prolapse quantification POP‐Q, aged 45–75 years without previous prolapse surgery.
Methods
Synthetic non‐absorbable mesh placed in the vesicovaginal space and sutured to the promontory (LS) or maintained by arms through pelvic ligaments and/or muscles (TVM).
Main outcome measures
Functional outcomes (pelvic floor distress inventory PFDI‐20 as primary outcome); anatomical assessment (POP‐Q), composite outcome of success; re‐interventions for complications.
Results
A total of 220 out of 262 randomised patients have been followed at 4 years. PFDI‐20 significantly improved in both groups and was better (but below the minimal clinically important difference) after LS (mean difference −7.2 points; 95% CI −14.0 to −0.05; P = 0.029). The improvement in quality of life and the success rate (LS 70%, 61–81% versus TVM 71%, 62–81%; hazard ratio 0.92, 95% CI 0.55–1.54; P = 0.75) were similar. POP‐Q measurements did not differ, except for point C (LS −57 mm versus TVM −48 mm, P = 0.0093). The grade III or higher complication rate was lower after LS (2%, 0–4.7%) than after TVM (8.7%, 3.4–13.7%; hazard ratio 4.6, 95% CI 1.007–21.0, P = 0.049)).
Conclusions
Both techniques provided improvement and similar success rates. LS had a better benefit–harm balance with fewer re‐interventions due to complications. TVM remains an option when LS is not feasible.
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At 4 years, Laparoscopic Sacropexy (LS) had a better benefit–harm balance with fewer re‐interventions due to complications than Trans‐Vaginal Mesh (TVM).
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At 4 years LS had a better benefit–harm balance with fewer re‐interventions due to complications than TVM.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objective
To assess the association between functional limitations related to mobility and urinary incontinence (UI) in elderly women.
Design
An observational cross‐sectional study.
Setting
Nine ...‘balance’ workshops in France.
Population
A total of 1942 community‐dwelling women aged 75–85 years, who were invited, based on voter registration lists, to a ‘balance assessment’.
Methods
Mobility and balance test results for incontinent women were compared with those for continent women according to the severity and type of incontinence.
Main outcome measures
Data on UI were collected using a self‐administered questionnaire (International Consultation on Incontinence Questionnaire—Short Form). Motor‐related physical abilities were assessed using standardised balance and functional gait tests.
Results
Forty‐two per cent of women had involuntary urine leakage, with daily leaks in 57% of them; 24% had stress UI, 31% had urge UI, and 37% had mixed UI. Results for each functional test were poorer for women with UI and the limitation was more pronounced when the incontinence was severe. Multivariate logistic regression analyses showed that balance and gait impairments were significantly and independently associated with urge UI (walking speed, lower versus higher quartile, odds ratio (OR) 2.2; 95% confidence interval (95% CI) 1.4–3.5; walking balance, unable versus able to do four tandem steps (OR 1.6; 95% CI 1.2–2.2) but not with stress UI.
Conclusions
In this large population of older women living at home, there was a strong association between limitation of motor and balance skills and UI, which was proportional to the severity of incontinence and related specifically to urge incontinence. These results offer new perspectives on the prevention and treatment of urge incontinence in elderly women.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
The aim of this review was to agree on a definition of the obstetric anal sphincter injuries (OASIS), to determine the prevalence and risk factors.
A comprehensive review of the literature on the ...obstetric anal sphincter injuries (OASIS), establishment of levels of evidence (NP), and grades of recommendation according to the methodology of the recommendations for clinical practice.
To classify obstetric anal sphincter injuries (OASIS), we have used the WHO-RCOG classification, which lists 4 degrees of severity. To designate obstetric anal sphincter injuries, we have used the acronym OASIS, rather than the standard French terms of "complete perineum" and "complicated complete perineum". OASIS with only isolated involvement of the EAS (3a and 3b) appears to have a better functional prognosis than OASIS affecting the IAS or the anorectal mucosa (3c and 4) (LE3). The prevalence of women with ano-rectal symptoms increases with the severity of the OASIS (LE3). In the long term, 35-60% of women who had an OASIS have anal or fecal incontinence (LE3). The prevalence of an OASI in the general population is between 0.25 to 6%. The prevalence of OASIS in primiparous women is between 1.4 and 16% and thus, should be considered more important than among the multiparous women (0.4 to 2.7%). In women with a history of previous OASIS, the risk of occurrence is higher and varies between 5.1 and 10.7% following childbirth. The priority in this context remains the training of childbirth professionals (midwives and obstetricians) to detect these injuries in the delivery room, immediately after the birth. The training and awareness of these practitioners of OASIS diagnosis improves its detection in the delivery room (LE2). Professional experience is associated with better detection of OASIS (LE3) (4). Continuing professional education of obstetrics professionals in the diagnosis and repair of OASIS must be encouraged (Grade C). In the case of second-degree perineal tear, the use of ultrasound in the delivery room improves the diagnosis of OASIS (LE2). Ultrasound decreases the prevalence of symptoms of severe anal incontinence at 1 year (LE2). The diagnosis of OASIS is improved by the use of endo-anal ultrasonography in post-partum (72h-6weeks) (LE2). The principal factors associated with OASIS are nulliparity and instrumental (vaginal operative) delivery; the others are advanced maternal age, history of OASIS, macrosomia, midline episiotomy, posterior cephalic positions, and long labour (LE2). The presence of a perianal lesion (perianal fissure, or anorectal or rectovaginal fistula) is associated with an increased risk of 4th degree lacerations (LE3). Crohn's disease without perianal involvement is not associated with an excess risk of OASIS (LE3). For women with type III genital mutilation, deinfibulation before delivery is associated with a reduction in the risk of OASIS (LE3); in this situation, deinfibulation is recommended before delivery (grade C).
It is necessary to use a consensus definition of the OASIS to be able to better detect and treat them.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK, ZRSKP
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