Current Women's Health Reviews - Volume 9, Issue 2, 2013

Cesarean section is the most common surgery performed in the United States with over 30% of deliveries occurring via this route. This number is likely to increase given decreasing rates of vaginal birth after cesarean section (VBAC) and primary cesarean delivery on maternal request, which carries the inherent risk for intraoperative complications. Urologic injury is the most common injury at the time of either obstetric or gynecologic surgery, with the bladder being the most frequent organ damaged. Risk factors for bladder injury during cesarean section include previous cesarean delivery, adhesions, emergent cesarean delivery, and cesarean section performed at the time of the second stage of labor. Fortunately, most bladder injuries are recognized at the time of surgery, which is important, as quick recognition and repair are associated with a significant reduction in patient mortality. Although cesarean delivery is a cornerstone of obstetrics, there is a paucity of data in the literature either supporting or refuting specific techniques that are performed today. There is evidence to support double-layer closure of the hysterotomy, the routine use of adhesive barriers, and performing a Pfannenstiel skin incision versus a vertical midline subumbilical incision to decrease the risk for bladder injury during cesarean section. There is also no evidence that supports the creation of a bladder flap, although routinely performed during cesarean section, as a method to reduce the risk of bladder injury. Finally, more research is needed to determine if indwelling catheterization, exteriorization of the uterus, and methods to extend hysterotomy incision lead to bladder injury.

Although a variety of the health benefits have been attributed to regular physical activity, some studies suggested that strenuous exercise may be considered as an independent risk factor for the onset of urinary incontinence in young women. The aim of this article is to provide a review of the scientific literature concerning the role of physiotherapy in the prevention and treatment of urinary incontinence in sport women. Stress urinary incontinence is defined as a leakage of urine during elevated intra-abdominal pressure that can occur during exercise. This dysfunction may affect the quality of life, carrying negative implications on psychological, social and athletic performance. Pelvic floor muscle training has been shown to be an effective treatment in women in general population. However, few studies have been conducted showing the effects of the pelvic floor training in sportswomen. In addition, there are no randomized clinical trials studying this subject. Evidence suggests that stress urinary incontinency may be related to delays in pelvic floor muscles contraction in response to sudden increase of intra-abdominal pressure. Further research is necessary to determine the pelvic floor muscles function in women that perform physical activity with different levels of exigency.

Obstetric fistula is a form of maternal morbidity which may occur in any woman of reproductive age who suffers from prolonged obstructed labor or traumatic attempt at vaginal delivery. The medical and social consequences of obstetric fistula can be life-shattering for women, their children and families. The principles of obstetric fistula repair have changed very little over the years, though a number of them are often modified by the cost, efficacy of treatment modality, and skill of the surgeon. Advances in other areas of surgery such as laparoscopic surgery have led to more precise identification of fistulous urogenital tracts and improved precision of tissue plane dissection and repair. Robotic surgery was a significant improvement in laparoscopy. It reduces operating fatigue and eliminates unpredictable movements and tremors common with human hands during laparoscopy. The introduction and wide spread use of surgical glue will ultimately reduce the need for interpositional tissue flaps. However, unavailability of resources to deploy these current trends in the management of obstetric fistula in resource poor setting may limit the use of these modalities in such areas where most of the cases occur.

Sex hormones have a substantial influence on the female lower urinary tract (LUT) throughout adult life. Estrogen deficiency, particularly when prolonged, is associated with a wide range of urogenital complaints, including frequency, nocturia, incontinence, urinary tract infections and the urge syndrome. Estrogen therapy may be of benefit for the irritative symptoms of urinary urgency, frequency, and urge urinary incontinence. This effect may result from reversal of urogenital atrophy and not a direct action on the lower urinary tract. Treatment with local estrogen cream seems to have an overall beneficial effect on the severity of SUI. Role of estrogen in urogenital atrophy is well established. Low-dose, vaginally administered estrogens have an important role in the treatment of urogenital atrophy in postmenopausal women and appear to be as effective as systemic preparations. The newer estriol and estradiol-containing vaginal hormone therapies are safe for short-term use. The vaginal delivery of estrogen causes enhancement of the efficacy of treatment of urogenital symptoms and avoids the need for daily dosage of systemic hormone replacement therapy (HRT). Estrogen replacement therapy may be efficacious in the treatment of women with recurrent lower urinary tract infections.

Introduction and Objectives: Vesicovaginal fistula (VVF) is the most common type of the genitourinary fistulae. The etiology in the developed countries is commonly following abdominal hysterectomy. In the underdeveloped countries, the etiology is prolonged complicated labor. The best approach for repair; whether abdominal or vaginal; is still debatable. Most experts agree that the optimal technique of repair depends on the surgeon’s familiarity with the approach performed. In the era of minimally invasive surgery, laparoscopy and robotic-assisted laparoscopy have gained popularity in the management of VVF; aiming to decreased morbidity, while preserving the same success rates of the conventional approaches. In this review, we address the role of these minimally invasive surgeries in the management of the VVF, with emphasis on the recent literature review. Materials and Methods: Literature search was done using Medline database with key words: vesicovaginal fistula, laparoendoscopic single site surgery, laparoscopy and robotic repair. Papers written in languages other than English were excluded from our review article. Results: Although many articles have reported laparoscopic repair of VVF, however most of them are case reports and there are only 6 articles that included more than 10 patients. Robotic assisted laparoscopic repair has been reported by 6 different centers, while LESS repair of VVF has been recently reported. Overall success rate was high and comparable with open repair. Most of reports use the classical O’Connor technique. The operative time was quite variable and overall the hospital stay was short. Conclusion: In experienced hands, both traditional and minimally invasive approaches have the same clinical equivalence. The laparoscopic approach requires laparoscopic experience. The daVinci system provides a three-dimensional magnified view, which provides better identification of the surgical planes. LESS repair is feasible too, but requires advanced laparoscopic experience due to the loss of triangulation, which makes it difficult for the free movement of the instruments.

Laparoscopic Burch colposuspension is an operation to help elevate the urethro-vesical junction so as to correct stress urinary incontinence. The paravaginal tissue of the urethro-vesical junction is elevated by fixing it with the Cooper’s ligament with the help of non-absorbable sutures or mesh. Subjective and objective cure rates are better with the non-absorbable sutures. Laparoscopy can be done via extra-peritoneal or intra-peritoneal approach; though most of the surgeons prefer intra-peritoneal approach. Laparoscopic technique is no way inferior to the laparotomy technique; rather it has the same efficacy like open Burch colposuspension in short, medium & long term results, (level 1 evidence). Intraoperative cystoscopy is mandatory as it can find out the accidental inclusion of the bladder, which if not detected, can lead to many urinary problems afterwards. Apart from this bladder injury related urinary complaint, post-operatively some other urinary complications are also reported e.g. de novo overactive bladder, voiding difficulties etc. though incidences are less. Pelvic organ prolapse-urinary incontinence sexual function questionnaire (PISQ) found that sexual functions have been improved after the operation. Due to the advent of tension free vaginal tape (TVT), trans-obturator tape (TOT) and, mini sling the popularity of Burch colpo suspension has been decreased. But after the FDA warning on uses of mesh, there is a resurgence of laparoscopic Burch colposuspension.

Overactive bladder is a common disorder that affects over 100 million adults worldwide though its prevalence has been grossly underestimated. The magnitude of this problem is increasing steadily with the growing elderly population, increased incidence of obesity, polypharmacy and increased awareness, making its treatment a challenging task for the physician. The treatment strategies may be nonpharmacologic or pharmacologic or both. Physical therapy techniques, such as bladder training, pelvic-floor exercises and electrical stimulation of the pelvic floor - are the nonpharmacological therapies that mitigate the sufferings of such patients. Anticholinergic agents remain the mainstay of the pharmacological therapy and act by decreasing or inhibiting the intensity of involuntary detrusor contractions. Immediate-release oxybutynin was the first dedicated antimuscarinic agent used for the treatment of overactive bladder symptoms. With geographic differences, other currently approved antimuscarinics are propiverine, tolterodine (immediate and extended release), trospium chloride (immediate and extended release), solifenacin (extended release), darifenacin (extended release) and fesoterodine(extended release). Still in the research phase and for use in refractory OAB are gabapentine and intradetrusor injection of botulinum toxin A. Symptom relief has been observed by more direct neuromodulatory techniques, such as acupuncture, posterior tibial nerve stimulation and sacral nerve stimulation, that address the underlying neurologic condition, although urodynamic data have not corroborated the same. Surgical intervention such as bladder augmentation, may rarely be resorted to in those with refractory urge incontinence and failure of conservative treatments. Eventually, the aim of all the treatment modalities is to improve the patients’ quality of life.

Urinary incontinence is a common and distressing condition known to adversely affect quality of life. It is widely prevalent and places a considerable financial burden on society. Stress urinary incontinence describes a symptom or a sign. A diagnosis of urodynamic stress incontinence can only be made following urodynamic investigation. This condition is defined as ‘the involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction. The aetiology of urodynamic stress incontinence is complex and remains poorly understood. There are several options available for the management of SUI: conservative, medical as well as surgical. The initial line of treatment in USI should be conservative, with lifestyle advice and pelvic floor muscle training. Medical management is a relatively new approach in the treatment of stress incontinence and should be considered after behavioural intervention and pelvic floor muscle training has failed and where there are no contra indications to the use of duloxetine. Surgery however remains the mainstay of treatment in women with severe stress incontinence or in those who fail to improve with conservative measures. The aim of this review is to describe the epidemiology of stress urinary incontinence and consider the various modalities for its conservative management

Interstitial Cystitis/Painful Bladder Syndrome is a controversial chronic disease characterized by pain, urgency and frequency. Patients with severe symptoms have a very miserable life. There is still no international consensus on its name, definition, investigations and management. American, European and Asian guidelines have been recently framed but differ on many important issues. Presentations of IC/PBS patients are highly individual with the same or similar symptoms expressed differently. However, an important aspect of the symptoms is their relation to micturition. Since no internationally accepted standards exist for diagnosis and treatment, considerable variation is observed in the patient investigations. Investigations are divided between mandatory and optional. Sonography of kidney-ureter-bladder and urine culture are mandatory investigations as they rule out other pathologies. However, there is no consensus on important investigations such as cystoscopy. Some urologists believe painful bladder syndrome to be a clinical disease diagnosed on the basis of history and minimum investigations, while according to others cystoscopy confirms the disease by ruling out other potential causes of the symptoms and also helps in management decision-making. & No standard protocol exists for treatment. All the available treatments work on a few patients and it is difficult to decide which treatment is best for a given patient. This dilemma has led to a policy of staged treatment where various treatment modalities are applied to the patient one after other, starting with less invasive and progressing to more invasive. Some treatment modalities like intravesical Botox and neuro-modulation are for patients with refractory IC/PBS only.

Aim of the review: Initial use of synthetic mesh in pelvic organ prolapse surgery involved use of custom made meshes. Custom made mesh involves cutting of a synthetic mesh into appropriate size and shape, and anchoring the mesh to the supporting structures using sutures. On the other hand, there are varieties of pre-designed commercially available mesh kits attached with trocars for insertion of mesh. This review aims to analyze the success rates, complications, and viability of custom made meshes and compare them with pre-designed mesh kits. Methods of literature search and analysis: A Pubmed search for the term “Vaginal mesh” revealed 1421 articles. Further narrowing the search using filters “Last 10 years”, “Humans” and excluding “Review articles”, we obtained 850 papers on vaginal mesh. Searching through these 850 papers, we found that 89 papers dealt with customised mesh in pelvic floor surgery. Papers are analyzed under the sub-headings efficacy in anterior and apical compartment, complications, comparison of custom mesh with predesigned mesh kits, and abdominal mesh repairs. Results: In the anterior compartment, anatomical failure rate for custom mesh is around 17%, and that of subjective failure rate is around 4.4%. In the Apical compartment repair, anatomic failure rate for customized mesh for apical compartment ranges from 0% to 7%. The risk of vaginal exposure for custom mesh ranges from 5 to 17%. New onset of dyspareunia was noted in 4.5% to 16.7% of patients. In terms of efficacy, custom mesh gives equally good success comparable to that of pre-designed mesh kits. Complication rates are similar between custom meshes and pre-designed mesh kits, with the exception of reduced blood loss in custom meshes. Customised meshes are relatively inexpensive compared to predesigned mesh kits. Conclusion: In terms of efficacy, customised mesh gives equally good success rates for pelvic organ prolapse surgery as compared to pre-designed mesh kits, with an added advantage of reduced cost. This is particularly relevant in developing countries where cost of surgery is of paramount importance for patients. Other advantage of custom made mesh kits is reduced blood loss.