Introduction and hypothesis
Pregnancy and childbirth are considered risk factors for pelvic floor dysfunction, including anorectal dysfunction. We aimed to assess the effect of obstetric events on ...anal incontinence and constipation after delivery.
Methods
We systematically reviewed the literature by searching MEDLINE, Embase and CENTRAL. We included studies in women after childbirth examining the association between obstetric events and anorectal dysfunction assessed through validated questionnaires. We selected eligible studies and clustered the data according to the type of dysfunction, obstetric event and interval from delivery. We assessed risk of bias using the Newcastle Ottawa Scale and we performed a random-effects meta-analysis and reported the results as odds ratios (ORs) with their 95% confidence intervals. Heterogeneity across studies was assessed using I
2
statistics.
Results
Anal sphincter injury (OR: 2.44 1.92–3.09) and operative delivery were risk factors for anal incontinence (forceps—OR :1.35 1.12–1.63; vacuum—OR: 1.17 1.04–1.31). Spontaneous vaginal delivery increased the risk of anal incontinence compared with caesarean section (OR: 1.27 1.07–1.50). Maternal obesity (OR:1.48 1.28–1.72) and advanced maternal age (OR: 1.56 1.30–1.88) were risk factors for anal incontinence. The evidence on incontinence is of low certainty owing to the observational nature of the studies. No evidence was retrieved regarding constipation after delivery because of a lack of standardised validated assessment tools.
Conclusions
Besides anal sphincter injury, forceps delivery, maternal obesity and advanced age were associated with higher odds of anal incontinence, whereas caesarean section is protective. We could not identify obstetric risk factors for postpartum constipation, as few prospective studies addressed this question and none used a standardised validated questionnaire.
(1) Objective: We aimed to report an update of the systematic review and meta-analysis by Baekelandt et al. (2016). (2) Method: We followed PRISMA guidelines to perform this systematic review. We ...searched MEDLINE, EMBASE, CENTRAL and additional sources and aimed to retrieve randomised controlled trials (RCTs), controlled clinical trials (CCTs) and prospective/retrospective cohort studies in human subjects that allowed direct comparison of vNOTES to laparoscopy. (3) Results: Our search yielded one RCT and five retrospective cohort trials. Pooled analysis of two subgroups showed that, compared to conventional laparoscopy, vNOTES is equally effective to successfully remove the uterus in individuals meeting the inclusion criteria. vNOTES had significantly lower values for operation time, length of stay and estimated blood loss. There was no significant difference in intra- and postoperative complications, readmission, pain scores at 24 h postoperative and change in hemoglobin (Hb) on day 1 postoperative.
Vaginal birth causes pelvic floor injury which may lead to urinary incontinence. Cell therapy has been proposed to assist in functional recovery. We aim to assess if intra-arterial injection of rat ...mesoangioblasts (MABs) and stable Vascular Endothelial Growth Factor (VEGF)-expressing MABs, improve recovery of urethral and vaginal function following simulated vaginal delivery (SVD). Female rats (n = 86) were assigned to either injection of saline (control), allogeneic-MABs (MABs
), autologous-MABs (MABs
) or allogeneic-MABs transduced to stably expressed VEGF (MABs
). One hour after SVD, 0.5 × 10
MABs or saline were injected into the aorta. Primary outcome was urethral (7d and 14d) and vaginal (14d) function; others were bioluminescent imaging for cell tracking (1, 3 and 7d), morphometry (7, 14 and 60d) and mRNAseq (3 and 7d). All MABs injected rats had external urethral sphincter and vaginal function recovery within 14d, as compared to only half of saline controls. Functional recovery was paralleled by improved muscle regeneration and microvascularization. Recovery rate was not different between MABs
and MABs
. MABs
accelerated functional recovery and increased GAP-43 expression at 7d. At 3d we detected major transcriptional changes in the urethra of both MABs
and MABs
-injected animals, with upregulation of Rho/GTPase activity, epigenetic factors and dendrite development. MABS
also upregulated transcripts that encode proteins involved in myogenesis and downregulated pro-inflammatory processes. MABs
also upregulated transcripts that encode proteins involved in neuron development and downregulated genes involved in hypoxia and oxidative stress. At 7d, urethras of MABs
-injected rats showed downregulation of oxidative and inflammatory response compared to MABS
. Intra-arterial injection of MABs
enhances neuromuscular regeneration induced by untransduced MABs and accelerates the functional urethral and vaginal recovery after SVD.
Does flatus incontinence matter? Cattani, Laura; Gillor, Moshe; Dietz, Hans Peter
International Urogynecology Journal,
10/2019, Letnik:
30, Številka:
10
Journal Article
Recenzirano
Introduction and hypothesis
This study aimed to determine whether incontinence to flatus is associated with women’s bother in a symptomatic population and with sonographically diagnosed external anal ...sphincter (EAS) trauma.
Methods
This is a retrospective study of women attending a tertiary urogynecological unit between May 2013 and November 2015. Baseline evaluation included a standardized interview with St. Mark’s Incontinence Score (SMIS) and visual analog scale (VAS) assessment for bother, as well as a physical examination and translabial pelvic floor ultrasound. At least one volume obtained covered the entire length of the EAS. These volumes were analyzed with the reviewer blinded to all clinical data.
Results
During the inclusion period, 1104 patients visited the unit. Fifty-three patients were excluded from the study for missing data, leaving 1051 for final analysis. Mean age was 57 years (56–58) and mean body mass index (BMI) 29.1 kg/m
2
(28.8–29.6). The prevalence of any anal incontinence (AI) and flatus incontinence were 16.4% (172/1051) and 13.9% (146/1051), respectively. In the group of patients with AI, mean SMIS was 11.8 (11.0–12.6), and mean VAS for AI bother was 5.4 (5.0–5.9). Significant EAS trauma was detected in 9.8% (103/1051) of patients and was associated with flatus incontinence (
p
= 0.002). Including a flatus incontinence question in the SMIS questionnaire improved the prediction of patient bother from AI (
R
2
87.8% versus
R
2
86.3%,
p
= 0.04).
Conclusions
Flatus incontinence is associated with ultrasound findings of EAS trauma and with higher patient bother from AI.
Background
Pregnancy and childbirth increase the risk for pelvic floor dysfunction, including sexual dysfunction. So far, the mechanisms and the extent to which certain risk factors play a role ...remain unclear.
Objectives
In this systematic review of the literature we aimed to determine risk factors for sexual dysfunction in the first year after childbirth.
Search Strategy
We searched MEDLINE, Embase and CENTRAL using the search strategy: sexual dysfunction AND obstetric events.
Selection Criteria
We included original, comparative studies, reported in English, that used validated questionnaires and the ICS/IUGA terminology for sexual dysfunction, dyspareunia and vaginal dryness.
Data Collection and Analysis
We assessed the quality and the risk of bias of the included studies with the Newcastle–Ottawa scale. We extracted the reported data and we performed random‐effects meta‐analysis to obtain the summary odds ratios (ORs) with 95% confidence intervals (95% CIs). Heterogeneity across studies was assessed using the I2 statistic.
Main Results
Anal sphincter injury was associated with increased odds for both sexual dysfunction (OR 3.00, 95%CI 1.28–7.03) and dyspareunia (OR 1.92, 95% CI 1.47–2.52). Episiotomy was associated with dyspareunia (OR 1.64, 95% CI 1.25–2.14), but not with sexual dysfunction (OR 1.90, 95% CI 0.94–3.84). Compared with spontaneous birth, caesarean section reduced the odds for dyspareunia (OR 0.68, 95% CI 0.54–0.86) but not for sexual dysfunction (OR 1.14, 95% CI 0.89–1.46). Instrumental vaginal birth increased the odds for sexual dysfunction (OR 1.70, 95% CI 1.05–2.76), yet no difference was found for dyspareunia (OR 1.82, 95% CI 0.88–3.75). One study of low quality reported on vaginal dryness and found no association with obstetric events.
Conclusions
Perineal trauma, rather than mode of birth, increases the odds for sexual dysfunction in the first year after childbirth.
Tweetable
Perineal trauma, rather than mode of birth, correlates with sexual dysfunction and dyspareunia postpartum. #dyspareunia #OASI #episiotomy
Tweetable
Perineal trauma, rather than mode of birth, correlates with sexual dysfunction and dyspareunia postpartum. #dyspareunia #OASI #episiotomy
Linked article This article is commented on by Rachel Pope, pp. 1029 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17065.
Objectives To assess the feasibility of acquiring adequate transperineal ultrasound (TPUS) volumes of the anal sphincter (AS) immediately after vaginal birth, the reproducibility of its measurements, ...and detecting defects therein. Methods Secondary analysis of TPUS volumes of the AS, acquired immediately after vaginal birth with a transversely oriented convex probe. Two independent experts ranked off‐line image quality as “inadequate,” “adequate,” or “ideal” using the Point‐of‐Care Ultrasound Image Quality scale. On “adequate” and “ideal” quality volumes, the length of the external AS at 6 and 12 o'clock, and the volume of the external and internal AS were measured. Additionally, volumes were screened for AS defects on tomographic ultrasound imaging. Subsequently, we rated the intra‐ and interrater agreement on those findings. Results Of 183 volumes, 162 were considered “adequate” or of “ideal” quality (88.5%). Reasons for “inadequacy” were shadow artifacts (16/21), poor resolution (3/21), incomplete acquisition (1/21), or aberrant AS morphology (1/21). The intrarater reliability of two‐dimensional (2D) and three‐dimensional (3D) measurements was excellent, whereas interrater reliability was fair to good for 2D measurements and good for 3D measurements. In those tomographic ultrasound imaging (TUI) sequences including AS defects, the intra‐ and interrater reliability of the defect measurement were excellent intraclass correlation coefficient (ICC) = 0.92 (0.80–0.94) and moderate ICC = 0.72 (0.63–0.79). In this cohort, there were only few (4/48; 8.3%) AS defects. However, grading them was poorly reproducible between experts. Conclusion TPUS of the AS immediately after vaginal birth yields adequate image quality and allows for reproducible measurements. In the few patients with AS defects, there was good agreement on the presence, but it was poor for the extent of defects.
To determine the prevalence of pelvic floor dysfunction (PFD) among pregnant women, their clustering and their association with body image disturbance (BID) up to 1 year postpartum.
Monocentric ...prospective cohort study.
University Hospitals Leuven.
Pregnant women attending for pregnancy care, first assessed prior to 14 weeks of gestation and agreeing to follow-up until 1 year postpartum.
Standardised questionnaires reporting on PFD and BID at 12-14 and 28-32 weeks of gestation, and again at 6-8 weeks and 1 year postpartum. We calculated the prevalence of PFD, how the cases clustered and how the cases correlated with BID using a linear mixed-model analysis. A minimum of 174 women with complete follow-up were required.
The questionnaires used were the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF), St. Mark's Incontinence Score (SMIS), Patient Assessment of Constipation Symptoms (PAC-SYM), Pelvic Organ Prolapse Distress Inventory (POPDI), Pelvic Organ Prolapse/Incontinence Sexual Questionnaire IUGA Revised (PISQ-IR) and the Body Image Disturbance Questionnaire (BIDQ).
Out of 208 women, 92.8% reported one or multiple symptoms of PFD at 28-32 weeks of gestation, dropping to 73.6% by 1 year postpartum. The most common symptoms were constipation (65.3% at 28-32 weeks of gestation and 42.8% at 1 year postpartum) and urinary incontinence (56.8% at 28-32 weeks of gestation and 35.1% at 1 year postpartum). After correcting for body mass index, parity and mode of delivery, the severity of BID was associated with the ICIQ-UI SF score (β = 0.016, range 0.007-0.024), the PAC-SYM score (β = 0.006, range 0.002-0.011) and the POPDI score (β = 0.009, range 0.005-0.012), but not with the SMIS score (β = 0.015, range -0.001 to 0.031) or the PISQ-IR score, in sexually active women.
Urinary incontinence, constipation and symptoms of prolapse have a measurable impact on BID.
Among the various oral affections that affect the felines, we can highlight the infraorbital fistula, which consists of a periapical osteolytic lesion (osteolysis caused by inflammation due to pulpal ...necrosis and bacterial contamination of the root canal), usually in the tooth. In the clinical examination of the animal the presence of infraorbital fistula with alteration in the fourth premolar tooth was verified. As a treatment, the Exodontia technique associated with the administration of antimicrobials and anti-inflammatories in the pre-operative period, and antimicrobials and analgesics in the pos-operative period were performed.
Entre las diversas afecciones orales que afectan a los felinos, podemos destacar la fístula infraorbitaria, que consiste en una lesión osteolítica periapical (osteolisis causada por inflamación derivada de la necrosis pulpar y contaminación bacteriana del canal radicular) generalmente en el diente. En el examen clínico del animal se constató la presencia de fístula infraorbitaria con alteración en el cuarto premolar. Como tratamiento se realizó la técnica de Exodoncia asociada a la administración de antimicrobianos y antinflamatorios en el preoperatorio, y antimicrobianos y analgésicos en el postoperatorio.
Dentre as várias afecções orais que acometem os felinos, podemos destacar a fístula infraorbitária, que consiste em uma lesão osteolítica periapical (osteólise causada por inflamação decorrente da necrose pulpar e contaminação bacteriana do canal radicular) geralmente no dente. No exame clínico do animal constatou-se a presença de fístula infraorbitária com alteração no dente quarto pré-molar. Como tratamento foi realizado a técnica de Exodontia associada à administração de antimicrobianos e antinflamatórios no pré-operatório, e antimicrobianos e analgésicos no pós-operatório.
The aims of this work were to create a robust automatic software tool for measurement of the levator hiatal area on transperineal ultrasound (TPUS) volumes and to measure the potential reduction in ...variability and time taken for analysis in a clinical setting. The proposed tool automatically detects the C-plane (i.e., the plane of minimal hiatal dimensions) from a 3-D TPUS volume and subsequently uses the extracted plane to automatically segment the levator hiatus, using a convolutional neural network. The automatic pipeline was tested using 73 representative TPUS volumes. Reference hiatal outlines were obtained manually by two experts and compared with the pipeline's automated outlines. The Hausdorff distance, area, a clinical quality score, C-plane angle and C-plane Euclidean distance were used to evaluate C-plane detection and quantify levator hiatus segmentation accuracy. A visual Turing test was created to compare the performance of the software with that of the expert, based on the visual assessment of C-plane and hiatal segmentation quality. The overall time taken to extract the hiatal area with both measurement methods (i.e., manual and automatic) was measured. Each metric was calculated both for computer-observer differences and for inter-and intra-observer differences. The automatic method gave results similar to those of the expert when determining the hiatal outline from a TPUS volume. Indeed, the hiatal area measured by the algorithm and by an expert were within the intra-observer variability. Similarly, the method identified the C-plane with an accuracy of 5.76 ± 5.06° and 6.46 ± 5.18 mm in comparison to the inter-observer variability of 9.39 ± 6.21° and 8.48 ± 6.62 mm. The visual Turing test suggested that the automatic method identified the C-plane position within the TPUS volume visually as well as the expert. The average time taken to identify the C-plane and segment the hiatal area manually was 2 min and 35 ± 17 s, compared with 35 ± 4 s for the automatic result. This study presents a method for automatically measuring the levator hiatal area using artificial intelligence-based methodologies whereby the C-plane within a TPUS volume is detected and subsequently traced for the levator hiatal outline. The proposed solution was determined to be accurate, relatively quick, robust and reliable and, importantly, to reduce time and expertise required for pelvic floor disorder assessment.
Introduction
Pregnancy and childbirth are considered risk factors for pelvic organ prolapse (POP). The long latency between obstetric events and morbidity hinders the establishment of cause-effect ...relationships. Recently, intermediate outcomes such as organ descent and levator avulsion (LA) have been identified. We aimed to assess the effect of obstetric events on symptoms and signs of POP and on LA.
Methods
We systematically reviewed the literature by searching PubMed/MEDLINE, Embase and Cochrane Library. We included studies in women examining associations between obstetric events and symptoms and signs of POP and LA, assessed through questionnaires, clinical examination and pelvic floor imaging. Two reviewers evaluated the studies for eligibility and for methodological quality/susceptibility to bias. We extracted study results and clustered them by outcome: symptoms of POP (sPOP), clinical findings of POP (cPOP) and LA. When appropriate, we performed a random-effect meta-analysis and reported the summary odds ratios (OR) with 95% confidence intervals. Heterogeneity across studies was assessed using the I
2
statistic.
Results
The first vaginal delivery was a risk factor for POP as measured by sPOP (OR: 2.65 1.81–3.88), cPOP (OR: 4.85 2.15–10.94) and in association with LA (OR: 41.6 4.13– 419.41). Forceps delivery was a risk factor for POP as measured by sPOP (OR: 2.51 1.34–4.69), cPOP (OR: 1.68 1.21–2.34) and in association with LA (OR: 5.92 3.75–9.34). Birth exclusively by caesarean was protective for sPOP (OR: 0.38 0.29–0.51) and for cPOP (OR: 0.29 0.20–0.41) and it did not confer any additional risk compared to nulliparity.
Conclusions
This review confirms a strong aetiological link between vaginal birth and POP, with the first vaginal and forceps delivery being the main determinants.
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