INTRODUCTION:Midurethral tapes (MUTs) were the most common surgical treatment for stress urinary incontinence (SUI) between 2008 and 2017. Transobturator tapes were introduced as a novel way to insert MUTs. Some women have experienced life-changing complications, and opt to undergo a total excision of transobturator tape (TETOT). There is a paucity in evidence about the outcomes of TETOT, which is a complex operation. This study aims to report clinical outcomes of all women who underwent TETOT in a specialist mesh center.METHODS:All women between 2017 and 2022 who underwent TETOT in one mesh center were reviewed. Background demographics and preoperative symptoms were recorded retrospectively. Outcome data were collected using patient global impression of improvement (PGI-I) scales via telephone review and analyzed using SPSS 25.RESULTS:Forty-five women underwent telephone review in May 2022, on average 27.9 months (range: 3-60) after TETOT. Mean age was 55 and body mass index (BMI): 30; 82% were postmenopausal, 20% were smokers, and 73.3% had recurrent SUI before excision. Indications for excision were infection (4%), vaginal exposure (24%), urethral perforation (9%), and chronic pain not associated with other complications (60%). Two women with recurrent SUI opted for a concomitant fascial sling; both reported a PGI of "very much improved" regarding SUI postoperatively. Only 12 women (26.5%) did not have SUI before excision; of these 9 (75%) reported new SUI postoperatively. Pain improved for 57.8%, but worsened for 24.4%. Although not statistically significant (p = 0.055), more women who underwent TETOT for pain alone reported worsening pain than those with pain with an additional complication (37% vs. 5.55%). Overall, 62.2% women felt "better" after their excision, 17.8% felt "worse."DISCUSSION:After TETOT, 62% of women felt better. Improvement in pain was reported by 58%-those with chronic pain without another complication reported improvement in pain less frequently (48% vs. 72%) and worsening pain more frequently (37% vs. 6%). Existing SUI worsened in 65% of women and 75% developed new SUI. There appears to be discordance between reporting global improvement with worsening of commonly measured clinical outcomes.CONCLUSION:Outcome data are important for counseling women about the risks and benefits of TETOT. Women and clinicians may have different attitudes to the possible benefits of TETOT, as evidenced by women reporting feeling better despite continuing pain or SUI. Conventional outcome measures do not adequately capture all outcomes that are important to patients.

Overactive bladder is a common and bothersome condition which has a major and measurable impact on sufferers' quality of life. The cardinal symptom of urgency, with or without urgency incontinence, frequency and nocturia is thought to be caused by abnormalities in detrusor smooth muscle function and/or sensory pathways. A structured assessment approach is of importance, including a detailed history of symptoms, medical and drug history and lifestyle factors such as fluid intake. Conservative management revolves around the key principles of fluid modification, avoidance of potential triggers and bladder retraining. Pharmacological options include antimuscarinic and beta agonist drugs. These medications have proven efficacy but compliance varies due to side effects and poor tolerability. Anti-cholinergic burden is an important factor to consider in prescribing to older women taking concurrent medications. If conservative and medical therapy is ineffective, further options include intra-detrusor botulinum toxin injections and neuromodulation.

This review article explores the occurrence of urinary tract infection in women – in pregnancy, in gynaecology, after menopause as well as those that are acquired in hospitals. It discusses the pathophysiology of these infections and the evidence that is currently present for different management modalities. It also discusses in-depth, the various causes and treatment modalities for recurrent urinary tract infections including the burden that it can bear on women and society.

Urogynaecological symptoms are commonly encountered problems in women of post-reproductive age, which have a major impact on quality of life in affected women. This review summarises a standardised approach to common urogynaecological problems in primary care, which focuses on making the correct diagnosis, assessing impact, evaluating for other relevant lifestyle and medical factors and indications for referral into secondary care.

Objectives To evaluate the values of perineal body (PB) and genital hiatus (GH) before and after posterior repair. We also evaluated the introital surface area (ISA)-a sum of transverse and longitudinal GH measurements. Methods This secondary analysis of a prospective case series included 94 women undergoing posterior vaginal prolapse surgery at a consultant urogynecology clinic between October 3, 2011, and October 2, 2014. Patients were examined in clinic using the pelvic organ prolapse quantification system with Valsalva maneuver, and in theatre pre- and postoperatively with traction. Results Immediately postoperatively, a statistically significant change (all P<0.001) was noted for GH (mean difference -0.59 cm), PB (-0.56 cm), and ISA (-0.87 cm) compared with preoperative measurement. This effect was maintained for GH (-0.42 cm) and PB (-0.40 cm) at 2 months' follow-up (both P<0.001), and for PB alone (-0.43 cm; P=0.04) at 8 months. ISA had a moderate correlation with GH (r=0.55). Conclusions Posterior repair significantly improved PB length at months 2 and 8, and GH length at month 2. ISA did not correlate with prolapse stage. Changes in GH were not maintained beyond postoperative month 2.

OBJECTIVE:To evaluate long-term sustainability of the Stop Traumatic OASI Morbidity Project (STOMP) in reducing the incidence of obstetric anal sphincter injury (OASI). METHODS:A prospective observational study of women undergoing vaginal delivery at a UK district general hospital between September 1, 2014, and February 28, 2017. The principles of STOMP involve encouraging upright positioning, verbal coaching to avoid expulsive pushing and to slow down delivery, and tactile support to the vertex to judge speed and slow down delivery. After a training period, STOMP was implemented for all vaginal deliveries. Clinical and demographic data on women affected by OASI were collected across a 30-month period. The primary outcome measure was the incidence of OASI. RESULTS:There were 8782 vaginal deliveries during the 30-month period after implementation of STOMP. There was a significant decrease in the mean incidence of OASI relative to the 9 months before implementation (P<0.001). There was a significant decrease in the incidence of OASI for both spontaneous vaginal and instrumental deliveries (both P<0.05). There was no change in the frequency of episiotomy. CONCLUSIONS:Implementation of STOMP led to a significant decrease in OASI, confirming the sustainability of this approach to improve outcomes.

Introduction and hypothesis Cystodistension may be offered as a treatment for patients with refractory overactive bladder. The reported efficacy is based on a number of case series. This study was designed to evaluate the efficacy of cystodistension in a randomized trial. Methods This was a randomized study comparing cystoscopy combined with cystodistension with cystoscopy alone. The primary outcome was improvement in the Urgency Perception Scale (UPS) score. Symptoms were assessed using the ICIQ Female Lower Urinary Tract Symptoms (ICIQ-FLUTS). Quality of life was assessed using the Urinary Distress Inventory (UDI). Results A total of 77 patients were recruited into the study with 42 randomized into the cystodistension arm and 35 into the cystoscopy-only arm. UPS scores had improved in both the cystodistension (41%) and cystoscopy (44%) arms at 6 weeks, but cystodistension provided no added benefit over cystoscopy alone. There was a significant improvement in ICIQ-FLUTS scores in the cystoscopy-only arm at 6 weeks (p = 0.01), but there was no significant improvement in the cystodistension arm (p = 0.09). At 6 weeks there were significant improvements in UDI scores in both arms (both p = 0.01). Despite statistical improvements at 6 weeks, no clinically therapeutic benefit was maintained by either procedure at 6 months. Conclusions Cystoscopy produces some short-term improvement in bladder symptoms, but cystodistension does not.

To compare the assessment of pelvic organ prolapse (POP) between the Pelvic Organ Prolapse Quantification (POP‐Q) system with Valsalva maneuver and intraoperative measurement with mechanical traction.

AIMS:There is evidence of an association between voiding parameters and the presence of overactive bladder symptoms. The aim of this study was to evaluate whether there is any association between pressure flow study parameters and the degree of health related quality of life impairment in women with OAB symptoms. The null hypothesis is that there is no significant correlation between quality of life domain scores and pressure flow study parameters. METHODS:One hundred and sixty-seven consecutive women with overactive bladder symptoms underwent evaluation with a quality of life assessment plus filling and voiding cystometry. These data were used to evaluate for any correlation between pressure flow study parameters and quality of life domain scores. RESULTS:Fifty-six out of 167 women had proven detrusor overactivity (DO). There were no differences in voiding parameters or quality of life scores between women with DO and women without DO. There was no consistent correlation identified between quality of life domain scores and pressure flow variables. CONCLUSIONS:There is no evidence of an association between increasing quality of life impairment and voiding parameters in this cohort.

This chapter explores post-delivery procedures and complications, including retained placenta, postpartum haemorrhage (PPH), vaginal and perineal lacerations, uterine inversion, vulval or perineal haematoma, and resuscitation of the newborn.

Introduction and hypothesis The aim of this study was to evaluate for any association between pretreatment cystometry results and outcome of treatment with mirabegron in women with overactive bladder (OAB) symptoms.Methods This was a prospective observational study of women with OAB symptoms that proved refractory to conservative management. All women underwent filling and voiding subtraction cystometry prior to further treatment. Women were treated with mirabegron 50 mg once daily, and outcomes were evaluated after 6 weeks' treatment. The primary outcome measure was change in symptoms as indicated by response to the Patient Global Impression of Improvement (PGI-I) scale. The presence of detrusor overactivity (DO), the highest detrusor pressure recorded during the filling phase, the presence of urodynamic stress incontinence (USI), cystometric capacity, voided volume, maximum flow rate and detrusor pressure at maximum flow were all compared between responders and nonresponders.Results The study population consisted of 169 women; response rate to mirabegron was 69.8 %. There was no association between the presence of DO or maximum detrusor pressure during filling and USI, cystometric capacity, maximum flow rate and detrusor pressure at maximum flow and treatment response. In a subgroup with OAB symptoms refractory to previous treatment with antimuscarinics, there was an association between the presence of DO and a positive treatment response (p = 0.02).Conclusions Overall, there is no association between urodynamic findings and response to treatment with mirabegron. This may reflect the fact that mirabegron's mode of action mechanisms are not measurable using cystometry. In women with refractory symptoms, however, the presence of DO is associated with a positive response to treatment.

This chapter outlines miscellaneous topics in gynaecology, such as urinary retention, sexual assault (including incidence, risks, examination, and management), and pharmacotherapeutics in gynaecology (drugs used in the treatment of pelvic inflammatory disease (PID), prophylactic antibiotics for emergency surgery, genital herpes, menorrhagia and dysmenorrhoea, and medical management of ectopic pregnancy and miscarriage).

Objective: To reduce the incidence of third and fourth degree perinea( tears.Study design: This was a quality improvement project followed by an audit of outcomes. The population consisted of all women delivering vaginally over a 12 month period following implementation of the quality improvement measures. Following a review of clinical factors associated with all third and fourth degree tears over a 3 month period and a review of relevant evidence, a series of measures to try and reduce the incidence of such tears were introduced. These measures were collectively known as STOMP (Stop Traumatic OASIS Morbidity Project). These were adopted by all staff in our unit, with an accompanying programme of workshops and a publicity campaign to promote staff engagement. Data were collected on all third and fourth degree tears for a 12 month period following project launch. The primary outcome was the incidence of third and fourth degree perineal tears over a 12 month period.Results: There were a total of 3902 vaginal births during the 12 month period following project launch. Following full STOMP implementation, there was a significant decrease in the incidence of third/fourth degree tears (4.7% vs 2.2%, p < 0.0001). The reduction was most pronounced in the first 5 months (4.7% vs 1.51%, p < 0.0001).Conclusions: STOMP is a simple and low cost series of measures that has lead to a significant decrease in the incidence of third and fourth degree tears in this cohort of women. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Mirabegron is a new beta 3 agonist for the treatment of overactive bladder (OAB). Although there are extensive data from randomised controlled trials, there is little real world evidence about its effectiveness and side effects. We conducted a prospective cohort study to evaluate the effectiveness of mirabegron as third-line treatment in patients with refractory OAB who did not benefit from antimuscarinic therapy and bladder drill.

INTRODUCTION AND HYPOTHESIS:This study aimed to evaluate any differences in the incidence of perineal trauma in women undergoing vaginal delivery following intrauterine fetal death (IUFD) versus live-births. This information would be of interest in evaluating the possible effect of fetal demise on the mechanism of labour in the second stage and thus may provide invaluable insights to contribute to our understanding of the impact of fetal tone on the mechanics of labour and delivery.METHODS:323 women who delivered vaginally following IUFD were matched with 1,000 women with a live-birth for age, parity, gestation and birth weight. Women undergoing assisted vaginal delivery and/or episiotomy were excluded.RESULTS:Women with an IUFD had a significantly lower risk of perineal trauma overall (relative risk 0.16) as well as a lower risk of obstetric anal sphincter injury specifically (RR 0.12).CONCLUSIONS:Women delivering vaginally after IUFD have a lower incidence of perineal trauma compared with women delivering a live infant. This may be due to differences in biomechanics following an IUFD.

Dear Editor, We thank Dr. Sivaslioglu [1] for his interest in the long-term results of our trial of a minisling versus “traditional” retropubic tape [2]. We agree with his point regarding success rates of adjustable minislings. At the time our study was conceived, single-incision slings were a relatively new concept, and the first adjustable minisling was not yet in widespread use. As well as the possibility of movement of tissue anchors, which we highlighted as a possible reason for the poorer success rate of the minisling arm of our study, the inability to adjust the tension of the minisling was undoubtedly a major factor. Although this has been overcome by the introduction of adjustable minislings, it should be noted that recent meta-analysis data of trials with at least 12 months’ follow-up also report full-length slings to be superior to minislings in terms of objective and subjective outcomes [3]. With respect to evaluating intrinsic sphincter deficiency (ISD), we chose not to include this aspect as part of our trial protocol, as we were keen to focus on the outcomes that were most applicable to patients. Whereas we agree that stratifying results by the presence of ISD would have given interesting insights, achieving the patient’s goal is known to correlate significantly with other measures of treatment success [4], and we therefore chose to focus on symptom relief as our primary outcomemeasure. Nonadjustable minislings have been shown by other authors to perform less well in patients with ISD [5], probably for the reasons outlined by Dr. Sivaslioglu as well as by us. The development of single-incision slings represents an ongoing evolution in continence surgery. Whereas the evidence base is increasing, clinicians should be encouraged to submit their outcomes to registries and databases so that our subspecialty can more definitively delineate which operation optimally fits which patient.