OBJECTIVE:The current standard for preterm birth (PTB) risk assessment is to measure cervical length (CL) using transvaginal ultrasound. A CL <25 mm at mid-gestation is considered to increase the risk of PTB in otherwise asymptomatic women. However, this method has only limited predictive capability, as most of the women delivering preterm do not present a short cervix1,2. Cervical softening has long been considered an important descriptive parameter of cervical status throughout pregnancy and due to technological advances, it has regained consideration as having potential to improve spontaneous PTB (sPTB) risk assessment3. In this study we evaluated differences in cervical stiffness measured mid-pregnancy with the aspiration-based Pregnolia System4 between pregnant women who ultimately delivered at term and the ones who had a spontaneous preterm birth; and we evaluated the performance of stiffness in predicting sPTB. STUDY DESIGN:We conducted a cross-sectional, prospective, cohort study (NCT02037334) of pregnant women (18-55 years) at 13 centers. Clinical population consisted of women presenting at their routine mid-pregnancy consultation (180/7 - 220/7 weeks' gestation) able to give informed consent. Exclusion and withdrawal criteria were active bleeding, premature rupture of membranes (PROM), active genital infection, known carrier of HIV or Hepatitis B or C, placenta previa, Müllerian anomalies, known or suspected study non-compliance, drug or alcohol abuse, cerclage or pessary in place, as well as CL <15 mm, or frailness / critical lesions of cervix. Cervical stiffness, assessed as Cervical Stiffness Index (CSI), was measured (three times and averaged) with the aspiration-based Pregnolia System, placed on the anterior lip of the cervix during a speculum examination, recording the vacuum pressure required to atraumatically displace cervical tissue by a fixed distance4. Stiffness was also determined through the maximum cervical compressibility ratio (Cervical Consistency Index, CCI) and cervical length measured transvaginally. Pain or discomfort scoring (from 0 - no pain to 10 - maximum possible pain), and delivery information were recorded. RESULTS:Among 1002 enrolled women, 990 had singleton pregnancies. Preterm birth rate (5.2%) in the whole dataset was considerably lower than expected, with 25 spontaneous among a total of 52 preterm births. Women with singleton gestations who experienced sPTB had significantly (p=0.039) lower mid-pregnancy mean CSI (median=65 mbar, IQR=(42,70), n=19) than those delivering at term (71 mbar, (51,97), n=948). CL and CCI did not differ significantly (see Table 1). Prior vaginal delivery (VD) was strongly associated with a softer cervix: in term singleton pregnancies, CSI was 15% lower in women with prior VD (64 mbar, (45, 85), n=358) compared to women without a prior VD (75 mbar, (55,103), n=590) (p<0.001). In women without prior VD, CSI discriminated term birth vs sPTB more strongly (59 mbar, (42,70), n=15 vs 75 mbar, (55,103), p=0.007), outperforming CL: AUC=0.703 (95% CI 0.584 - 0.821) vs 0.592 (95% CI, 0.446 - 0.738). A generalized linear model including CSI and CL provides a marginal improvement (AUC=0.729, 95% CI, 0.621-0.837). Procedure discomfort was minimal (0.51±1.32), with no device-related serious adverse events. CONCLUSION:Women with singleton pregnancies delivering spontaneously preterm had a significantly lower cervical stiffness than those delivering at term. This finding is in line with the literature results with other methods5 and demonstrates that the cervical stiffness can be assessed at the vaginally exposed portion of the cervix.

INTRODUCTION:Urinary incontinence is a common complaint of both general practitioners and specialists. An accurate basic diagnosis with a structured medical history and bladder diary, urine analysis, gynaecological examination including pelvic floor assessment and a full bladder cough test can be supplemented by sonography, cystoscopy and urodynamic testing. This will help to differentiate between the different types of urinary incontinence, such as urge incontinence, stress incontinence and overflow incontinence. Treatment should be based on the type of urinary incontinence. Conservative treatments such as pelvic floor physiotherapy and pessaries can be supplemented by electrical stimulation for OAB and overflow incontinence, and various procedures such as TVT or bulking agents for stress incontinence, sacral neurostimulation for OAB and overflow incontinence.

OBJECTIVES:Endocrine drugs represent an important cornerstone of endometriosis therapy. Pharmaceutical alternatives with similar efficacy remain out of sight in the near future. Aim of this study is to investigate attitudes and perceptions concerning endocrine therapies among affected women. STUDY DESIGN:An online survey was distributed via social media in Austria, Germany, and Switzerland. Primary endpoints were satisfaction, attitudes and perceptions towards endocrine endometriosis drugs and secondary outcomes differences regarding demographic variables. RESULTS:Of 1420 respondents, 63.5 % (n = 901) described their own attitude towards these drugs as rather negative. The most frequently reported unfavorable associations and experiences were sideeffects in general (85.5 %, n = 1181), change in libido (67.5 %, n = 932), hormone cycle disruptions (65.9 %, n = 910), and inefficiency at alleviating symptoms (38.2 %, n = 527). In total, 66.1 % (n = 935) were not satisfied with endocrine drugs for endometriosis. Age ≤ 30 years, living in a large city, and having an academic degree were significantly correlated to a more negative perception of these drugs and greater dissatisfaction with current endocrine endometriosis drugs. CONCLUSIONS:Among women with endometriosis - and particularly among those aged ≤30 years, being large-city residents, or holding an academic degree - there appears to be a relevant degree of rejection and wariness towards endocrine endometriosis drugs. Given the prevalence of endometriosis and the few pharmaceutical alternatives on the horizon, these data point a growing need for further research and development of non-hormonal drugs for the treatment of endometriosis.

ObjectivesTo better understand the neuropathophysiology of overactive bladder (OAB) in women by characterising supraspinal activity in response to bladder distention and cold stimulation.Subjects/Patients and MethodsWe recruited 24 female participants, 12 with OAB (median [interquartile range, IQR] age 40 [32–42] years) and 12 healthy controls (HCs) without lower urinary tract (LUT) symptoms (median [IQR] age 34 [28–44] years), and assessed LUT and cognitive function through neuro‐urological examination, 3‐day bladder diary, urodynamic investigation, and questionnaires. Functional magnetic resonance (MR) imaging using a 3‐T scanner was performed in all participants during automated, repetitive bladder filling and draining (block design) with 100 mL body temperature (37 °C) saline using a MR‐compatible and MR‐synchronised infusion–drainage device until strong desire to void (HIGH‐FILLING/DRAINING) and bladder filling with cold saline (4 °C, i.e. COLD). Whole‐brain and region‐of‐interest analyses were conducted using Statistical Parametric Mapping, version 12.ResultsSignificant between‐group differences were found for 3‐day bladder diary variables (i.e. voiding frequency/24 h, P < 0.001; voided volume/void, P = 0.04; and urinary incontinence [UI] episodes/24 h, P = 0.007), questionnaire scores (International Consultation on Incontinence Questionnaire‐Female LUT symptoms [overall, filling, and UI scores, all P < 0.001]; the Overactive Bladder Questionnaire short form [symptoms and quality‐of‐life scores, both P < 0.001]; the Hospital Anxiety and Depression Scale [anxiety P = 0.004 and depression P = 0.003 scores]), as well as urodynamic variables (strong desire to void, P = 0.02; maximum cystometric capacity, P = 0.007; and presence of detrusor overactivity, P = 0.002). Age, weight and cognitive function (i.e. Mini‐Mental State Examination, P = 1.0) were similar between groups (P > 0.05). In patients with OAB, the HIGH task elicited activity in the superior temporal gyrus, ventrolateral prefrontal cortex (VLPFC), and mid‐cingulate cortex; and the COLD task elicited activity in the VLPFC, cerebellum, and basal ganglia. Compared to HCs, patients with OAB showed significantly stronger cerebellar activity during HIGH‐FILLING and significantly less activity in the insula and VLPFC during HIGH‐DRAINING.ConclusionsThe present findings suggest a sensory processing and modulation deficiency in our OAB group, probably as part of their underlying pathophysiology, as they lacked activity in essential sensory processing areas, such as the insula. Instead, accessory areas, such as the cerebellum, showed significantly stronger activation compared to HCs, presumably supporting pelvic‐floor motor activity to prevent UI. The novel findings of the present study provide physiological evidence of the necessity to consider non‐bladder aetiologies of bladder symptoms.

Antibiotikaverschreibungen wegen Harnwegsinfektionen (HWI) gehoren nach jenen bei den oberen Atemwegsinfektionen zu den haufigsten Antibiotikaverschreibungen in der ambulanten Praxis.1, 2Der weitverbreitete Antibiotikaeinsatz fuhrte in den vergangenen Jahren zur Zunahme von Antibiotikaresistenzen. Verschiedene nationale und internationale Guidelines haben deshalb zum kritischen Einsatz von Antibiotika in der Behandlung der unkomplizierten HWI aufgerufen.3–6 In dieser Ubersichtsarbeit werden die Evidenz des Einsatzes und die verzogerte Gabe von Antibiotika bei einfachen und komplizierten Harnwegsinfektionen erlautert und es wird auf Alternativen bei rezidivierenden Harnwegsinfektionen eingegangen.

Recurrent Urogynecological Infections Abstract. Changes in the urogenital microbiome of the bladder, urethra, vagina and cervix can cause recurrent infections. We distinguish between obligate and facultative pathogens. In the case of facultative pathogens, treatment with antibiotic, antiviral or antifungal drugs should only be considered in cases with attributable symptoms. Sexually transmitted diseases (STD) manifest either urogenitally alone or in association with an ascending infection of the adnexa as a pelvic inflammatory disease. STD may be asymptomatic, as in cases of chlamydia, or may cause a high burden of symptoms, impairment of quality of life or infertility. The aim of this minireview is to give an overview of the pathogenicity of the different germs and their treatment.

Proposal of a systematic approach to assess Deep infiltrating endometriosis (DIE) through pelvic Magnetic resonance imaging (MRI) using the Enzian classification and examination of inter-rater agreement. Three radiologists reviewed 23 MRI of patients with pelvic DIE at one tertiary referral center retrospectively and independently. Inclusion criteria were intraoperative confirmation of DIE and MR imaging according to ESUR (European Society of Urogenital Radiology) guidelines. Assessment of the anatomical pelvic compartments was performed using a manual based on the Enzian classification with step-by-step instructions using recommended planes and sequences presented here. Interrater agreement was measured using kappa statistics. According to the intraoperative site lesions in 53 anatomical compartments were present. Interrater agreement was best for compartments A (0.255) and FB (0.642). For FI (0.204) and B (0.146) it was slight, there was poor agreement for C (− 0.263), FA (− 0.022), and FO (− 0.030), respectively, and as for FU, no ureter infiltration was described. MRI as a noninvasive diagnostic tool offers essential advantages regarding classification and therapy planning for patients with DIE. However, its assessment is difficult and a more systematic approach is needed. Our proposed manual based on the Enzian classification is reproducible and could support radiologists and gynecologists.

Purpose Comparison of preoperative magnetic resonance imaging (MRI) with intraoperative findings in patients with deep infiltrating endometriosis (DIE) by means of the ENZIAN score. Methods This retrospective two-center study includes 63 patients with deep infiltrating endometriosis, who underwent surgery between 2012 and 2016 at both the University Hospital of Zurich and the Cantonal Hospital of Schaffhausen. Inclusion criteria were a preoperative pelvic MRI and intraoperative or bioptic confirmation of DIE. The preoperative MRI findings were compared with the intraoperative results by means of the ENZIAN score. Furthermore, the various MRI sequences were analyzed for their diagnostic value based on a Likert scale. Results Sensitivity and negative predictive values of MRI confirmed by surgery were 95.2% and 91.7% (lesions in the vaginal/rectovaginal space), 78.4% and 56% (uterosacral ligaments), 91.4% and 89.7% (rectum/sigmoid colon), 57.1% and 94.1% (myometrium), 85.7% and 98.3% (bladder), and 73.3% and 92.2% (intestine), respectively. T2 axial and sagittal MRI sequences in combination with a T1 sequence were diagnostically sufficient. Conclusions The MRI-based ENZIAN score correlates well with the intraoperative findings, enabling a better planning of the surgical procedure for patients and physicians. However, considerable difficulty and a poorer comparability result from the variations in sequences used in the detection of this multifaceted disease. Therefore, a standardization of MRI protocols used in the detection of DIE will be a crucial step towards increased diagnostic validity and the ENZIAN score may be used as an anatomical land map and valuable communication tool between radiologists and gynecologists.

Bladder outlet obstruction affects up to every fourth woman. This condition is causing difficulties to void. Patients complain about frequency, an urge to void, or they describe the feeling of post-void residual urine. Increased post-void residual urine or a pathological micturition pattern with increased pressure or pathological flow curves are suggestive for a bladder outlet obstruction. Common causes are genital organ prolapse, previous incontinence surgery, or dysfunctional voiding. Correspondingly, the underlying etiology is determining therapy: surgical correction of the pelvic organ prolapse usually eliminates the obstructive situation; a tightly placed incontinence sting should be loosened or incised, white dysfunctional disorders can be well addressed by pelvic floor rehabilitation.

Free AccessBlasenentleerungsstörung: ein Symptom, viele UrsachenDavid A. ScheinerDavid A. ScheinerLeiter Urogynäkologie, Klinik für Gynäkologie, Universitätsspital ZürichSearch for more papers by this authorPublished Online:May 22, 2018https://doi.org/10.1024/1661-8157/a002971PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreUnter «Symptome des unteren Harntrakts» oder «Lower Urinary Tract Symptoms» (kurz LUTS) fasssen wir die unterschiedlichen Blasenbeschwerden zusammen, die – je nach zugrundeliegender Pathologie – in der Speicher- oder in der Entleerungsphase auftreten können [1]. Betrifft die Pathologie die Speicherphase, resultieren daraus irritative Symptome oder überaktive Blasenbeschwerden (Overactive Bladder Syndrom, OAB) wie imperativer oder häufiger Harndrang, nächtliches Wasserlassen oder Dranginkontinenz, wogegen Auswirkungen auf die Entleerungsphase zu obstruktiven Blasenentleerungsstörungen wie Zögern beim Wasserlassen, schwachem oder unscharfem Harnstrahl, Pressenmüssen zum Wasserlösen, Nachtröpfeln, chronischer Restharnbildung oder sogar Überlaufblase führen.Generell können Pathologien der Blase wie Harnweginfekte oder Blasensteine, krankhafte Veränderungen der Prostata (Hyperplasie oder Prostatitis) oder der Urethra (Urethritis, Strikturen) die LUTS verursachen. Eine Haupt- ursache ist die vergrösserte Prostata, z.B. im Rahmen der benignen Prostatahyperplasie (BPH), die zu einer Blasenauslassstörung (Bladder Outlet Obstruction, BOO) mit OAB-Beschwerden führen kann. Inzidenz und Prävalenz von BPH und LUTS nehmen mit dem Alter zu, was gerade in unserer alternden Population zu berücksichtigen ist. So steigt die Prävalenz von LUTS je nach Studie von 8 % bei Männern in der vierten Lebensdekade auf 35 % in der siebten, sie liegt bei 56 % in der sechsten bis achten, dann bei 70 % in der neunten und beträgt schliesslich 90 % in der zehnten Lebensdekade [2]. Altersunabhängig sollte jedem Auftreten einer LUTS ärztlich nachgegangen werden. Die allgemein- oder fachärztlichen (urologischen) Untersuchungen erfolgen unter Berücksichtigung der möglichen zugrundeliegenden Ursachen und Komorbiditäten wie z.B. Diabetes mellitus. Die Abklärung beinhaltet situationsgerecht unter anderem die Urinanalyse zum Ausschluss eines Harnweginfekts, die Rektalpalpation zur Beurteilung der Prostata, das Führen eines Miktions- oder Blasentagebuchs, das die Beurteilung der Miktionsfrequenz und -mengen am Tag und in der Nacht gestattet, die PSA-Bestimmung (Prostata-spezifisches Antigen), die sonografische Bestimmung der Restharnmenge und der Prostata sowie die Zystoskopie zum Ausschluss von Blasenpathologien (Blasensteine oder -tumoren).Die Therapie der LUTS hängt von Ursache und Schweregrad ab. In dieser Praxis-Ausgabe wird die Problematik der LUTS von Cermak und Putman an einem konkreten Fallbeispiel demonstriert und das mögliche Vorgehen diskutiert [3].BibliografieAbrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al.: The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21: 167–178. First citation in articleCrossref Medline, Google ScholarParsons JK: Benign prostatic hyperplasia and male lower urinary tract symptoms: epidemiology and risk factors. Curr Bladder Dysfunct Rep 2010; 5: 212–218. First citation in articleCrossref Medline, Google ScholarCermak S, Putman S: Blasenentleerungsstörung beim Mann: ein Symptom, viele Ursachen. Praxis 2018; 107: 593–598. First citation in articleLink, Google ScholarDr. med. David A. Scheiner, Oberarzt mit erweiterter Verantwortung, Leiter Urogynäkologie, Klinik für Gynäkologie, Universitätsspital Zürich, Frauenklinikstrasse 10, 8091 Zürich, E-Mail david.scheiner@usz.chFiguresReferencesRelatedDetails Volume 107Issue 11Mai 2018ISSN: 1661-8157eISSN: 1661-8165 InformationPraxis (2018), 107, pp. 563-563 https://doi.org/10.1024/1661-8157/a002971.© 2018Hogrefe AGPDF download

Zusammenfassung. Das komplexe Zusammenspiel der anatomischen Strukturen am Beckenboden hat in der Evolution zur Kontinenz von Blase und Darm, dem sexuellen Erleben und der Reproduktion geführt. Diese Fähigkeiten haben alle eine wichtige individuelle und auch übergeordnete Rolle, dank derer erst soziale Interaktionen möglich werden. Um die Funktionen besser zu verstehen, sind anatomische zugrundeliegende Konzepte essentiell. Was in früheren Jahrhunderten durch Leichendissektionen an Wissen gewonnen wurde, wird heutzutage durch moderne Bildgebung und Bildverarbeitung erweitert. Im folgenden Artikel wollen wir den Leserinnen und Lesern eine Übersicht der anatomisch wichtigen Strukturen am Beckenboden geben.

Female pelvic floor: anatomy and normal function Abstract. In the course of evolution, the complex interaction of anatomical structures of the pelvic floor has led to bladder and bowel continence, sexual sensations and reproduction. All these functions and abilities play an important individual and social role, thanks to which higher interactions have become possible. For a better understanding of these functions, underlying anatomical concepts are essential. The knowledge gained through dissection of corpses in earlier centuries is now being expanded through modern imaging techniques and image processing. In the following article, we want to give readers an overview of the anatomically important structures and the functions of the pelvic floor.

Zusammenfassung. Bis zu jede vierte Frau ist von Blasenentleerungsstörungen betroffen. Darunter verstehen wir die erschwerte Entleerung der Blase. Blasenentleerungsstörungen können sich subjektiv durch häufigen und starken Harndrang oder Restharngefühl äussern. Erhöhter Restharn und / oder eine pathologische Miktion mit erhöhten Druckwerten und / oder pathologischen Flusskurven objektivieren die Störung. Häufige Ursachen sind ein Genitaldeszensus oder iatrogen bedingt ein Zustand nach Inkontinenzeingriffen. Daneben kann die Blasenentleerungsstörung auch dysfunktional bedingt sein. Entsprechend richtet sich die Therapie nach der Ursache: Die Korrektur des Deszensus führt meist zur Behebung der Miktionsproblematik, eine zu straff gelegte Inkontinenzschlinge soll gelockert oder gespalten werden, und dysfunktionale Störungen lassen sich gut mittels Beckenbodenrehabilitation angehen.

review article the topography, the interactions and functions of pelvic muscles, ligaments and nerves are demonstrated. The term ligament in the pelvic floor, especially in the levels I and II after DeLancey, is different from the one used in orthopedics. The ligament in the pelvic floor is a condensation of connective tissue and not a classic tendon that anchors a muscle to a bone. Ligaments in the pelvic floor are mixed structures that contain arteries and veins, lymphatic vessels, and nerves. They also contain smooth and striated muscles in order to adapt to different volumes of the bladder, the uterus and rectum. This kind of adaptation and function is focus of recent studies. Also the normal variability of organ movement before it yields to a pathologic state like prolapse, and the change of organ function after surgical mesh insertion are not completely elucidated yet.

Zusammenfassung. OAB (overactive bladder syndrome) ist zwar ein häufiges Leiden, doch wird es oft nicht diagnostiziert und deshalb nicht behandelt. Die Behandlung erfolgt symptomatisch. Im Praxisalltag muss vorgängig eine Basis-(Ausschluss)-Diagnostik durchgeführt werden. Das Führen eines Blasentagebuchs ist sowohl für die Diagnostik als auch für den Verlauf wichtig. Eine urogynäkologische Abklärung mit Urodynamik empfiehlt sich in unklaren Situationen und beim Vorliegen einer gemischten Symptomatik mit Symptomen einer Belastungsinkontinenz oder bei gleichzeitigem Vorliegen einer Blasenentleerungsstörung. Die Therapie erfolgt Schritt für Schritt. Schon einfache Verhaltensänderungen und ein Blasen- und Beckenbodentraining können die Symptomatik deutlich verbessern. Viele Patientinnen profitieren aber zusätzlich von der medikamentösen Therapie. Jahrzehntelang standen dazu alleinig Anticholinergika zur Verfügung. Doch die Langzeitcompliance ist unter diesen Medikamenten gering. Neu erweitern β3-Adrenorezeptor-Agonisten das therapeutische Spektrum: Bei ähnlicher Wirkung unterscheidet sich das Nebenwirkungsprofil unter anderem durch das Fehlen von Mundtrockenheit. Bei therapierefraktärer OAB steht die intravesikale Injektion von Onabotulinumtoxin A als sehr effektive Therapie zur Verfügung. In seltenen Fällen ist auch eine Neuromodulation indiziert.

Specific knowledge of urinary incontinence (UI) and its interrelation with physical and cognitive health is essential to working towards prevention of UI and to improving quality of treatment and care. The purpose of this study was to determine the association between UI and the activities of daily living (ADL) hierarchy scale, the cognitive performance scale (CPS) and comorbid conditions.

Background Escherichia coli. infections are increasing worldwide in community and hospital settings. The E toll O-antigen is a promising vaccine target. We aimed to assess the safety and immunogenicity of a bioconjugate vaccine containing the O-antigens of four E coli serotypes (ExPEC4V).Methods In this multicentre phase 1b, first-in-human, single-blind, placebo-controlled trial, we randomly assigned (1:1) healthy adult women with a history of recurrent urinary tract infection (UTI) to receive a single injection of either intramuscular ExPEC4V or placebo. The primary outcome was the incidence of adverse events among vaccine and placebo recipients throughout the study. Secondary outcomes included immunogenicity and antibody functionality, and the incidence of UTIs caused by E coli vaccine serotypes in each group. This study is registered with ClinicalTrials.gov, number NCT02289794.Findings Between Jan 20,2014, and Aug 27,2014,93 women received target-dose ExPEC4V and 95 received placebo. The vaccine was well tolerated: no vaccine-related serious adverse events occurred. Overall, 56 (60%) target-dose vaccines and 47 (49%) placebo recipients experienced at least one adverse event that was possibly, probably, or certainly related to injection. Vaccination induced significant IgG responses for all serotypes: at day 30 compared with baseline, O1A titres were 4.6 times higher, O2 titres were 9.4 times higher, O6A titres were 4.9 times higher, and O25B titres were 5.9 times higher (overall p<0.0001). Immune responses persisted at 270 days but were lower than those at 30 days. Opsonophagocytic killing activity showed antibody functionality. No reduction in the incidence of UTIs with 10(3) or more colony-forming units per mL of vaccine-serotype E coli was noted in the vaccine compared with the placebo group (0.149 mean episodes vs 0.146 mean episodes; p=0.522). In post-hoc exploratory analyses of UTIs with higher bacterial counts (>= 10(5) colony-forming units per mL), the number of vaccine serotype UTIs did not differ significantly between groups (0.046 mean episodes in the vaccine group vs 0.110 mean episodes in the placebo group; p=0.074). However, significantly fewer UTIs caused by E coli of any serotype were noted in the vaccine group compared with the placebo group (0.207 mean episodes vs 0.463 mean episodes; p=0.002).Interpretation This tetravalent E coli bioconjugate vaccine candidate was well tolerated and elicited functional antibody responses against all vaccine serotypes. Phase 2 studies have been initiated to confirm these findings.