International Urogynecology Journal

Lower Urinary Tract Symptoms in Relation to Leiomyoma Volume, Location, and Position in Reproductive-aged Women in the USA

Uterine leiomyomata are widely believed to contribute to lower urinary tract symptoms in women, but it is unclear whether leiomyoma size, position, and location have important implications for these symptoms. We assessed whether greater leiomyoma volume, anterior position, and subserosal location were associated with urinary incontinence and frequent urination in a racially diverse, nationwide sample of premenopausal women in the USA. A cross-sectional analysis of 477 premenopausal women from 12 USA sites undergoing evaluation for laparoscopic radiofrequency ablation or myomectomy for leiomyomata was carried out. Multivariable logistic regression models examined associations between leiomyoma volume, position, and location documented in clinical imaging reports and participant-reported urinary incontinence and distressing urination frequency, adjusting for age, race, parity, and body mass index. Among the 477 participants, 27.9% reported at least weekly incontinence, 72.8% distressing daytime urination frequency, and 63.4% frequent night-time urination. Greater total leiomyoma volume was associated with at least weekly incontinence of any type (OR 1.05, 95% CI 1.02-1.07, per 20-ml increase) and at least weekly stress-predominant incontinence (OR 1.04, 95% CI 1.01-1.07, per 20-ml increase), but not distressing daytime or night-time urination frequency. Although subserosal leiomyoma position was associated with a 2.01-fold (95% CI 1.14-3.56) greater odds of frequent night-time urination, no significant associations between leiomyomata location or position and incontinence were detected. In this multicenter sample of women seeking treatment for symptomatic leiomyomata, greater leiomyomata volume was associated with weekly any-type and stress-type incontinence, but leiomyoma position and location were not independently associated with urinary incontinence.

An in-home rehabilitation program for the treatment of urinary incontinence symptoms in endometrial cancer survivors: a single-case experimental design study

Abstract Introduction and hypothesis There is a high prevalence of urinary incontinence among endometrial cancer survivors. They are also known to present with pelvic floor muscle alterations. Evidence on the effects of conservative interventions for the management of UI is scarce. This study aims at verifying the effects of an in-home rehabilitation program, including the use of a mobile technology, to reduce UI severity in endometrial cancer survivors. Methods This study used a single-case experimental design with replications. Primary outcome for UI severity was the pad test, and secondary outcomes were the ICIQ-UI SF questionnaire and 3-day bladder diary. Pelvic floor muscle function was assessed using 2D-transperineal ultrasound and intravaginal dynamometry. Adherence was documented using mobile technology and an exercise log. Visual and non-parametric analyses of longitudinal data were conducted. Results Results show a reduction in UI severity for 87.5% of participants, with a significant relative treatment effect of moderate size (RTE: 0.30). Significant small relative treatment effects were found for the quick contraction and endurance dynamometric tests. Conclusion This study provides new evidence that endometrial cancer survivors can improve the severity of their UI following an in-home rehabilitation program, including the use of a mobile technology. This mode of delivery has the potential to address a gap in access to pelvic floor physiotherapy services for survivors of EC living in rural and remote communities.

Comparison of long-term bowel symptoms after laparoscopic radical hysterectomy versus abdominal radical hysterectomy in patients with cervical cancer

Abstract Introduction and hypothesis The objective of this study was to compare the long-term bowel symptoms between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) in patients with cervical cancer. Methods A total of 207 patients who underwent radical hysterectomy (79 underwent LRH and 128 underwent ARH) at Peking University First Hospital from January 2010 to August 2020 were enrolled and their bowel symptoms were investigated using the Colorectal Anal Distress Inventory-8 (CRADI-8) of the Pelvic Floor Distress Inventory-20. The prevalence and severity of bowel symptoms were compared in the LRH and ARH groups, and multivariate analysis was performed to determine the factors associated with bowel symptoms. Results There was no difference in the CRADI-8 scores between the two groups. However, the prevalence of straining at stool was significantly higher in the ARH group than in the LRH group (19.5% versus 1.3%, p<0.001), and the score was significantly higher in the ARH group than in the LRH group too (0.4 versus 0, p<0.001). The prevalence of incomplete defecation was significantly higher in the ARH group than in the LRH group (13.3% versus 3.8%, p=0.029), and the ARH group also had a significantly higher score than the LRH group (0.3 versus 0.1, p=0.028). Multivariate analysis showed that ARH and postoperative interval were independent risk factors for the development of straining at stool. Conclusions Patients with cervical cancer who underwent ARH may be more likely to develop symptoms related to constipation than those who underwent LRH. This finding has to be interpreted with caution owing to the study design.

Surgical management of vaginal cancer and concomitant complete uterovaginal prolapse

Pre-rehabilitation of the pelvic floor before radiation therapy for cervical cancer: a pilot study

The objective was to evaluate pelvic floor muscle (PFM) function regarding strength, activation and incontinence, approximately 1 month before and after radiation therapy in women with cervical cancer. This was a pilot study of 49 women with cervical cancer at stages I to III. These women attended an educational session with a physical therapist who taught them to perform preventive pelvic floor muscle exercises (PFMEs; slow and fast contractions and the "knack") at home before, during and after radiation therapy. The women received instructions for performing PFME prior to radiation therapy. The modified Oxford scale, electromyography (EMG), the International Consultation on Incontinence Questionnaire Short Form to assess urinary incontinence and two questions for faecal and gas incontinence were used. Twenty-eight women (57%; mean age = 44 years, range 27-66) completed the study, 21 (43%) were lost to follow-up. There was no significant change from baseline to post-radiation therapy in muscle strength, EMG records and incontinence (p > 0.05). The median of PFM strength was equal at baseline and after intervention (median = 2; IQR = 1). The results of this study suggest that pre-rehabilitation teaching PFMEs might be a protective factor for preserving PFM strength and preventing incontinence 1 month after radiation therapy. It is a feasible intervention.

Urinary tract morbidity after nerve-sparing radical hysterectomy in women with cervical cancer

Nerve-sparing radical hysterectomy (NSRH) has been developed as a method of cervical cancer treatment to reduce surgical morbidity compared with radical abdominal hysterectomy. The aim of this study was to analyze the short- and long-term effects of NSRH on urinary tract function. A study group of 117 patients underwent NSRH type C1 with pelvic lymphadenectomy for cervical cancer stages IB1-IB2 without adjuvant radiotherapy at our department. A total of 106 patients aged 21-74 years (mean age 44.8) were available for follow-up at 1 year after surgery. A transurethral catheter was left in place for 48 h after surgery, and the postvoid residual (PVR) volume was measured after its removal. One week before surgery and 12 months after NSRH, lower urinary tract function was evaluated by an urodynamic examination. Five days after surgery, the PVR volume was greater than 100 ml in 5 patients (4.7%) and a suprapubic catheter was inserted into these women for bladder training over the following days. Within 14 days after surgery, urination without PVR was achieved in all women who underwent surgery. Postoperatively, a slight increase in the average maximum bladder cystometric capacity was recorded from 420 to 445 ml (p value 0.009) without prolonging the voiding time. Other urodynamic parameters were not significantly different before and 12 months after NSRH. In this series, NSRH preserved voiding function and bladder sensation at 1 year and did not appear to compromise oncological outcome.

Prevalence of pelvic floor dysfunction and sexual dysfunction in cervical cancer survivors: a systematic review and meta-analysis

Pelvic floor dysfunction (PFD) and female sexual dysfunction (FSD) are symptoms that affect the quality of life of patients with cervical cancer (CC) after treatment. Our purpose was to estimate the prevalence of urinary incontinence (UI) and fecal incontinence (FI) associated with PFD and prevalence of FSD in CC patients. We searched PubMed, Embase, and the Cochrane Library from database inception to 31 January 2021 and selected articles assessing UI, FI and FSD in women with CC. Observational studies were included if they investigated UI, FI, and FSD. We included 14 of the 1,233 studies: 7 investigated FSD, 9 UI, and 3 FI. The results were highly heterogeneous because of the different populations and treatment methods. The prevalence of FSD, UI, and FI in CC patients after treatment was 45.0% (95% CI, 21.8-68.3%), 34.1% (95% CI, 25.5-42.7%), and 11.1% (95% CI, 4.8-17.3%). The results showed that different countries were the source of high heterogeneity of UI and FI (P<0.001). In this meta-analysis, the prevalence of PFD and FSD was high. These results are important for drawing attention to PFD and its early prevention and rehabilitation.

Modified KDPIF Technique in Vulvar Reconstruction: An Alternative Approach to the Conventional Technique with Reduced Complications

Currently, the reconstruction of vulvar defects presents a significant challenge for surgeons. The traditional keystone design perforator island flap (KDPIF) has emerged as a mainstream option owing to its reliable blood supply and procedural simplicity. However, postoperative complications such as flap scar contracture and urethral stricture remain prevalent. Therefore, this study introduces a Z-plasty-modified KDPIF technique designed to optimize flap tension distribution and reduce scar contracture while preserving the advantages of traditional KDPIF. We conducted a retrospective study including 58 patients between 2016 and 2023. Of these, 28 received traditional KDPIF and 30 received modified KDPIF. Postoperative clinical outcomes were collected for all patients. In this study, 30 patients underwent the modified KDPIF procedure, while 28 underwent the traditional KDPIF procedure. The average operation time for the modified KDPIF groups was 81.6 min with a flap size of 98.7 cm This study establishes that the modified KDPIF technique is a safe and effective surgical approach. It preserves conventional KDPIF benefits while reducing the risk of functional impairments, such as postoperative urethral/vaginal stenosis, and alleviating postoperative scar complications.

The incidence and risk factors of occult malignancy in patients receiving vaginal hysterectomy for pelvic organ prolapse

The aim of this study was to assess the incidence and risk factors for premalignant and malignant pathology in patients receiving vaginal hysterectomy (VH) and pelvic floor repair (PFR) for pelvic organ prolapse (POP). We performed a retrospective cohort study of pathological results after VH and PFR of 569 women at our institution from January 2011 through December 2020. Age, body mass index (BMI), POP-Q stage, and preoperative ultrasound results were evaluated as risk factors for occult malignancy. Six of the 569 patients (1.1%) had unanticipated premalignant uterine pathology and 2 (0.4%) had unanticipated malignant uterine pathology (endometrial cancer). There was no significant difference in the incidence of premalignant or malignant uterine pathology according to age, BMI, and POP-Q stage. However, if endometrial pathology is confirmed on preoperative ultrasonography, the probability of confirming malignant pathology increases (OR 4.63; 95% CI 1.84-51.4; p=0.016). The incidence of occult malignancy during VH for POP was significantly lower than that found in hysterectomy owing to benign disease. In the case of POP patients, for whom uterine-conserving surgery is not absolutely contraindicated, it can be performed. However, if endometrial pathology is confirmed by preoperative ultrasonography, uterine-conserving surgery is not recommended.

Vaginal stenosis in women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study of vaginal measurements, risk for sexual dysfunction and quality of life

Radiotherapy (RT) for cervical (CC) and endometrial cancer (EC) is known to lead to vaginal stenosis (VS), but the comparison between vaginal anatomical measurements and the risk of sexual dysfunction presents a wide variety of results among the literature. Thus, we sought to assess the prevalence of VS, vaginal measurements, sexual dysfunction and QOL in women with CC and EC submitted to pelvic RT with or without previous surgery. Cross-sectional study that included 61 women with CC and 69 with EC. VS was classified by the Common Terminology Criteria for Adverse Effects version 5.0 (CTCAE v5.0), sexual function by the validated Female Sexual Function Index (FSFI) and QOL by the validated World Health Organization questionnaire (WHOQOL-BREF). Acrylic cylinders were used for vaginal measurements. Uni-/multivariate analyses to address factors associated with VC in both groups were performed. The prevalence of VS was 79% and 67% within patients with CC and EC, respectively. Vagina length was decreased in both groups without statistical difference (7.2 ± 1.7 vs. 6.6 ± 1.8;p = 0.072). Vaginal diameter was significantly higher (p = 0.047) in women with EC (25.4 ± 6.3) than in those with CC (23.1 ± 5.7). Sexual dysfunction was highly prevalent for both CC and EC (88% vs. 91%; p = 0.598). There was no difference in all WHOQOL-BREF domains between women with CC and EC. VS is highly prevalent in CC and EC patients, with vaginal length decreased in both groups but with a higher vaginal diameter in those with EC. Nevertheless, sexual dysfunction is highly prevalent in both groups.

Pelvic floor muscle assessment by digital palpation and translabial ultrasound of women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study

We hypothesized that anatomical changes in the pelvic floor muscles (PFM) could be detected using four-dimensional translabial ultrasound (4D TLUS) in patients with cervical (CC) or endometrial cancer (EC) who underwent pelvic radiotherapy (RT) as digital palpation may present sensitivity limitations. This was a cross-sectional study that included 64 women (26 with CC and 38 with EC). PFM function was assessed by digital palpation, grading muscle strength according to the Modified Oxford Scale and by 4D TLUS. Ultrasonographic variables were: levator plate angle, hiatal area, puborectalis muscle thickness, puborectalis strain and levator ani muscle integrity. These variables were also correlated with clinical and sociodemographic data from all these patients. A 5% significance level was adopted. When assessed by digital palpation, no significant difference was found in PFM strength between women with CC and those with EC (p = 0.747). However, when assessed by 4D TLUS, women with CC presented greater thickening of the left (p = 0.039) and right (p = 0.014) lower portion of the puborectalis muscle during PFM contraction compared to those with EC. After pooling the groups, higher cancer staging (p = 0.028) was associated with smaller narrowing in the symphysis-levator distance, and shorter RT finishing duration (< 60 months) was associated with higher thickening in the left (p = 0.029) and right (p = 0.013) upper portion of the puborectalis muscle during PFM contraction as well as a shorter menopause duration (p = 0.007 and p = 0.002, respectively). Anatomical changes in the puborectalis muscle during PFM contraction were detected by 4D TLUS within gynecological cancer patients after pelvic RT.

Physical Activity, Quality of Life, and Pelvic Floor Disorders Before and After Hysterectomy for Gynecological Cancer: A Prospective Cohort Study

Abstract Introduction and hypothesis This study investigated physical activity (PA) levels and health-related quality-of-life (HRQoL) before and after, and associations between pelvic floor disorders (PFD) and PA/HRQoL after, hysterectomy for gynecological cancer. Methods Secondary analysis of a longitudinal cohort study, with assessments before, 6 weeks, and 3 months after hysterectomy for gynecological cancer. The International Physical Activity Questionnaire-short form was used to assess PA and European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-C30 (QLQ-C30) to assess HRQoL. Changes over time were analyzed using generalized estimating equations or linear mixed models. Associations between PFD with PA and HRQoL were analyzed using logistic regressions and analyses of variance. Results Of 126 participants, median age 63 years, most had endometrial (69%) and/or stage 1 cancer (72%) and underwent total hysterectomy (65%). Pre-surgery, 39% met PA guidelines, increasing to 53% 3 months post-surgery (+14%, 95% CI 2–25). Mean global health status/QoL domain scores from the QLQ-C30 did not change significantly (+4.4/100 points, 95% CI −0.8 to 9.6). Three months post-surgery, whether participants met PA guidelines was not associated with PFD. Participants with anal incontinence or double incontinence had lower global health status/QoL scores than participants without these symptoms (mean (SD) AI 61.4 (17.8) vs no AI 72.5 (18.7), p = 0.006; DI 61.5 (17.9) vs no DI 71.7 (18.8), p = 0.019). Conclusion PA levels were low pre- and post-surgery but worse preoperatively. This presents an opportunity for prehabilitation interventions to optimize physical function. There was no association between meeting PA guidelines and PFD. Global health status/QoL was slightly below population norms pre- and post-surgery. Lower HRQoL was associated with some symptoms of PFD.

Incidence and Outcomes of Occult Uterine Cancer in Uteri Removed for Prolapse

Abstract Introduction and Hypothesis To identify the incidence of occult endometrial cancer diagnosed following hysterectomy for the repair of pelvic organ prolapse, and compare patient outcomes to a control cohort of preoperatively diagnosed endometrial cancer patients. Methods A retrospective cohort study of patients ≥50 years with endometrial cancer between 2010 and 2020 was performed. Demographic, clinical, surgical, and oncologic variables were compared between occult endometrial cancer and preoperatively diagnosed endometrial cancer cohorts. Results One thousand seventy-two patients were included, of which 30 (2.8%) had occult endometrial cancer diagnosed after prolapse surgery and 1042 (97.2%) were in the preoperatively diagnosed historic cohort. The incidence of occult endometrial cancer was 0.56% for all hysterectomies performed for pelvic organ prolapse. Patients in the occult endometrial cancer cohort were more likely to have grade I disease (85.2% vs. 52.1%, p &lt; 0.001), less likely to have lymphovascular space invasion (10.7% vs. 31.8%) or &gt;50% myometrial invasion (11.1% vs. 24.0%, p = 0.004) compared to the preoperatively diagnosed patients. Ten occult endometrial cancer patients (33.3%) underwent a second staging procedure; 83.3% ( n = 25) of patients received care in compliance with comprehensive national cancer guidelines. Five-year recurrence free survival was 95.0% (95% CI 85.4–100%) and 66.8% (95% CI 59.3–74.4%) for preoperatively diagnosed cohort and occult endometrial cancer cohort, respectively, while 5-year overall survival was 90.9% (95% CI 78.9–100%) and 83.0% (95% CI 75.5–90.5%), respectively. Conclusions The rate of incidental endometrial cancer after hysterectomy for pelvic organ prolapse was 0.56% in our cohort. Most occult diagnosed patients are diagnosed with early-stage and low-grade disease. The majority received care concurrent with National Comprehensive Cancer Network recommendations.

An assessment of urethral radiation exposure in the treatment of endometrial and rectal cancers

Female survivors of endometrial and rectal cancers have increased risk of urinary incontinence. Survivors with prior radiation therapy are counseled against mesh incontinence surgery. We hypothesize that urethral radiation dose varies based on modality which may influence surgical risks. We aimed to demonstrate urethral radiation dose differences between vaginal brachytherapy (VBT) and external beam radiation therapy (EBRT). This is a retrospective cohort study of women exposed to VBT for endometrial cancer and EBRT for rectal cancer. The urethra was contoured on CT imaging to calculate radiation doses in centigray (cGy). The primary outcome was the percent of treatment radiation dose estimated to be received by the urethra based on the volume dose to 0.2 cc of urethra. Secondary outcomes were point doses to the bladder neck, mid-urethra, and total mean urethral dose. Descriptive statistics described demographic characteristics. Bivariate analyses compared urethral radiation dose based on radiation modality. Between 2014-2017, 32 women treated were included: 18 with VBT and 14 with EBRT. Mean ± SD urethral volume doses were lower in VBT (1266 cGy ± 533, 42.2% of prescribed treatment dose) compared to EBRT (5051 cGy ± 192, 100.2% of prescribed treatment dose), p < 0.0001. VBT also had significantly lower mean total urethral dose and point doses to bladder neck and mid- urethra compared to EBRT (p < 0.0001). The female urethra is exposed to significantly less radiation in VBT compared to EBRT. These data highlight that modality of pelvic radiation should be considered in treatment counseling on urinary incontinence in women.

Prevalence of histological abnormalities in hysterectomy specimens performed for prolapse. A systematic review and meta-analysis

The practice of histopathological assessment of the uterus following hysterectomy for benign indications including pelvic organ prolapse (POP) surgery is common and often routine. While pathology is not anticipated, the finding of pathology requiring further action is always a concern, in particular CIN (cervical intraepithelial neoplasia) or cervical/uterine malignancy. We aimed to perform a systematic review to understand the prevalence of actionable uterine and cervical pathology in hysterectomy specimens performed for POP. A literature search was performed in January 2020 of MEDLINE, Embase and CINAHL using the Healthcare Databases Advanced Search platform. Included studies reported CIN and/or uterine/cervical malignancy in histological assessment of hysterectomy specimens performed purely for POP. Meta-analysis of prevalence was performed using the MetaXL ( www.epigear.com ) add-in for Microsoft Excel. Six hundred seventy-seven records were identified, out of which 34 studies were eligible. Overall prevalence (95% confidence interval [CI]) of endometrial cancer in 33 studies was 0.004 (0.003-0.006), I The risk of actionable pathology is low, but not negligible. The variation between populations is wide. The prevalence of finding such pathology supports the routine practice of sending all hysterectomy specimens performed for POP for histological assessment.