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Resume Objectif Examiner les donnees sur les risques et les avantages de l'utilisation du laser vaginal dans la prise en charge du syndrome genito-urinaire de la menopause et de l'incontinence urinaire a l'effort. Utilisateurs cibles Gynecologues, urogynecologues, urologues et autres professionnels de soins qui evaluent, conseillent et soignent les femmes presentant un syndrome genito-urinaire de la menopause ou une incontinence urinaire a l'effort. Population cible Femmes adultes atteintes d'un syndrome genito-urinaire de la menopause ou d'incontinence urinaire a l'effort qui cherchent des options therapeutiques de rechange ou complementaires aux œstrogenes topiques, aux hydratants vaginaux non hormonaux, a la physiotherapie, aux dispositifs intravaginaux et a la chirurgie. Options Le present document compare le traitement du syndrome genito-urinaire de la menopause et de l'incontinence urinaire a l'effort par laser vaginal et par œstrogenes topiques. Resultats Les resultats a l'etude sont les taux objectifs et subjectifs de reponse au traitement, les observations histologiques et les complications liees aux interventions. Donnees Nous avons interroge les bases de donnees PubMed, Medline, Cochrane et Embase a l'aide des mots-cles « genitourinary syndrome of menopause », « vaginal laser », « topical estrogen » et « urogenital atrophy ». Nous n'avons tenu compte que des etudes menees chez l'humain et redigees en anglais. Des articles ont ete ajoutes jusqu'a la fin de septembre 2016. Nous nous sommes penches sur les directives cliniques et les lignes directrices de societes de specialistes. Nous avons egalement examine les etudes de cohorte observationnelles ou prospectives lorsque cela etait possible. Seules les etudes portant sur des groupes d'au moins 20 personnes ont ete retenues; les articles non evalues par les pairs ont ete exclus. Methodes de validation Le contenu et les recommandations ont ete rediges et acceptes par les auteurs principaux. Le Conseil d'administration de la SOGC a approuve la version finale avant publication. La qualite des donnees probantes a ete evaluee au moyen des criteres de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Avantages, inconvenients et couts Nous nous attendons a ce que cette mise a jour technique profite aux patientes presentant un syndrome genito-urinaire de la menopause, car elle renseignera les medecins traitants sur les diverses options therapeutiques et leur fera connaitre les avantages et les risques potentiels associes au laser vaginal. Ainsi, les patientes seront en mesure de prendre des decisions eclairees avant d'entreprendre un traitement. Aucun mefait ou cout direct n'est associe a la mise en œuvre de cette directive clinique. Commanditaire SOGC. Declarations sommaires 1.L'evaluation histologique par biopsie de la paroi vaginale indique que l'amelioration a court terme de la maturation epitheliale entrainee par le laser vaginal est sensiblement la meme que celle entrainee par les œstrogenes locaux (moyenne). 2.Des etudes observationnelles a court terme menees sur un petit nombre de patientes ayant eu recours au laser vaginal font etat d'une diminution des symptomes (secheresse, brulements, demangeaisons, dysurie, dyspareunie) et d'une amelioration des indices de satisfaction sexuelle (basse). 3.Des etudes observationnelles a court terme menees sur un petit nombre de patientes ayant eu recours au laser vaginal montrent une amelioration des symptomes de l'incontinence urinaire a l'effort (basse). Recommandations 1.Le laser vaginal peut etre envisage pour le soulagement a court terme des symptomes associes au syndrome genito-urinaire de la menopause chez les patientes qui ne veulent pas ou ne peuvent pas (contre-indications) recevoir d'œstrogenes locaux (conditionnelle, basse). 2.On ne dispose pas de donnees probantes suffisantes pour considerer que le laser vaginal est equivalent aux œstrogenes locaux pour le traitement du syndrome genito-urinaire de la menopause (atrophie vulvovaginale, symptomes touchant les voies urinaires inferieures, dysfonctions sexuelles) (forte, tres basse). 3.On ne dispose pas de donnees probantes suffisantes pour offrir le laser vaginal de preference aux autres options pour la prise en charge efficace de l'incontinence urinaire a l'effort, comme la reeducation des muscles du plancher pelvien, les pessaires ou la chirurgie (forte, tres basse). 4.L'utilisation a long terme du laser vaginal pour le traitement du syndrome genito-urinaire de la menopause ou de l'incontinence urinaire a l'effort est encore experimentale; elle devrait etre effectuee dans le cadre de protocoles d'essais cliniques bien concus visant a en determiner l'innocuite et l'efficacite (forte, tres basse). 5.Le laser vaginal ne devrait pas etre utilise pour prevenir les infections urinaires recurrentes, comme aucune etude n'appuie cette indication (forte, tres basse).

Objectives To evaluate technology use, eHealth literacy and feature preferences for a smartphone application with patient portal among women with pelvic floor disorders (PFD). Methods A survey was developed by the authors including demographics, and eHealth Literacy Scale (eHEALS; scored out of 40, higher score reflecting higher eHealth literacy). Women with PFDs attending one of 3 urogynecology clinics were recruited (July-September 2020). Due to COVID-19 restrictions, participants completed the survey online (via SimpleSurvey) or by phone. 99 women were successfully contacted. 45 declined to participate or did not complete the survey (13 reported no access to email or smartphone) and 54 completed the survey (54.5%). Statistics are descriptive. Results 41 (75.9%) were aged 30-69, and 52 (96.3%) had a high school diploma or higher. 51 (94.4%) owned a smartphone deviceand 42 (77.8%) ever used a smartphone application. Mean eHEALS score was 28.1 +/- 6.2. Most reported knowing how/where to find useful health information online. Only 29 (53.7%) were comfortable assessing quality of online resources, and 18 (33.3%) felt confident using online information to make health decisions. 45 (83.3%) felt that a smartphone application could positively impact satisfaction, communication and coordination of PFD care. Most valued application features included PFD information resources (94.4%), decision aids (92.6%), and communication with healthcare team (90.7%). Conclusions Many women with PFD would value a smartphone application to support shared decision-making. Users should be involved in the feature selection process. Barriers to use of this technology among women with PFDs should be further explored.

Vaginal vault prolapse afflicts millions of women and evokes significant psychosocial and pelvic floor dysfunction. The risk factors and modalities of conservative management are discussed in this study. There remains controversy in the optimal surgical management. This review serves to study the clinical conundrum of the decision-making process to utilize the mesh and the approach. In-depth evaluation of mesh-related postsurgical complications as compared to those associated with the native tissue is explored.

Introduction: Overactive bladder (OAB) syndrome is a highly prevalent and costly condition worldwide, with negative impact on health-related quality of life. Although many guidelines exist and anticholinergics are considered to be the mainstay of pharmacological treatment, data are lacking regarding optimal treatment duration. Therefore, the aim of this study was to determine practice patterns of Canadian urologists and gynecologists regarding duration of OAB pharmacotherapy.Methods: A 14-question survey was designed and survey links (English and French) were sent by email to all practicing urologists and gynecologists registered with the Canadian Urological Association and the Society of Obstetricians and Gynecologists of Canada via the associations’ email lists. The SurveyMonkey website served as platform where responses were collected and stored.Results: A total of 301 physicians completed the questionnaire; 250 respondents (83%) prescribe anticholinergics or beta-3-adrenoceptor agonist (mirabegron) in their practice, and 202 (81%) start patient treatment with the lowest recommended medication dose. One hundred and twelve respondents (45% of those who prescribe OAB medications) classified OAB pharmacotherapy as a lifelong management strategy, whereas 130 (52% of those who prescribe OAB medications) think that OAB pharmacotherapy should be administered for a defined time period. Six-month and one-year time periods of drug treatments are the most commonly chosen answers given by physicians who treat their patients for a defined duration.Conclusions: There is general agreement among Canadian urologists and gynecologists that OAB treatment should be started with the lowest recommended medication dose. A slim majority of respondents think that OAB pharmacotherapy should be administered for a defined duration.

Objective This technical bulletin reviews the evidence relating to risks and benefits of using intravaginal laser technology in the management of genitourinary syndrome of menopause and stress urinary incontinence. Intended Users Gynaecologists, urogynaecologists, urologists, and other health care professionals who assess, counsel, and provide care for women with genitourinary syndrome of menopause and stress urinary incontinence. Target Population Adult women with genitourinary syndrome of menopause and stress urinary incontinence seeking complementary or alternative treatment options to topical estrogen, non-hormonal vaginal moisturizers, physiotherapy, intravaginal devices, and surgery. Options The discussion relates to intravaginal laser treatments for genitourinary syndrome of menopause compared with topical estrogen and that for stress urinary incontinence. Outcomes The outcomes of interest are objective and subjective rates of response to treatment, histologic outcomes, and procedural complications. Evidence PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words "genitourinary syndrome of menopause," "vaginal laser," "topical estrogen," and "urogenital atrophy." Results were restricted to English and human research. Articles were included until the end of September 2016. Clinical practice guidelines and guidelines of specialty societies were reviewed. Included studies were observational or prospective cohort when available. Only publications with study groups larger than or equal to 20 individuals were included, and non–peer-reviewed papers were excluded. Validation Methods The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework. Benefits, Harms, and/or Costs It is expected that this technical bulletin will benefit patients with genitourinary syndrome of menopause by ensuring treating physicians are aware of all treatment options including the potential benefit and associated risk with intravaginal laser therapy. This should guide patient informed consent before such procedures are undertaken. There are no direct harms or costs identified with the implementation of this guideline. Sponsors The SOGC. Summary Statements 1.Histologic evaluation has shown a similar short-term improvement in vaginal epithelial maturation in post-procedural vaginal wall biopsies with the use of intravaginal laser as that seen with local estrogen (Moderate). 2.Short-term observational studies of small patient number with the use of intravaginal laser have demonstrated reductions in symptoms (including dryness, burning, itching, dysuria, and dyspareunia) and improvements in sexual satisfaction indices (Low). 3.Short-term observational studies of small patient number with the use of intravaginal laser have demonstrated improvements in symptoms of stress urinary incontinence (Low). Recommendations 1.In patients declining or with apparent contraindication to local estrogen, intravaginal laser therapy may be considered for short-term relief of symptoms associated with genitourinary syndrome of menopause (Conditional, Low). 2.There is insufficient evidence to offer intravaginal laser therapy as an equivalent modality to local estrogen for the treatment of genitourinary syndrome of menopause (including vulvovaginal atrophy, lower urinary tract symptoms, and sexual dysfunction) (Strong, Very Low). 3.There is insufficient evidence to offer intravaginal laser therapy as an effective modality for the treatment of stress urinary incontinence over alternate managements such as pelvic floor physiotherapy, incontinence pessaries, or surgery (strong, very low). 4.Long-term use of intravaginal laser therapy for the management of genitourinary syndrome of menopause or stress urinary incontinence remains experimental and should remain within the protocols of well-executed clinical trials in attempts to establish its safety and efficacy (Strong, Very Low). 5.Intravaginal laser therapy should not be offered to patients to prevent recurrent urinary tract infections as no literature exists to support such use (Strong, Very Low).

It is not uncommon to be challenged with the dilemma of deciding the best mode of delivery in a patient with a history of previous pelvic floor surgery. We hypothesized that the trend would be a predilection towards cesarean section delivery in the context of a previous pelvic floor surgery, especially amongst Urogynaecologists. A nation-wide survey was sent through the Society of Obstetrics and Gynaecology of Canada to all physician members to assess the practice patterns regarding the preferred mode of delivery after pelvic floor surgery. A hundred and three members replied. Forty-seven percent would recommend a cesarean section (CS) when pregnant after a previous midurethral sling (MUS), 27.2 % would allow vaginal delivery, 10.7 % would not be affected in their decision by the MUS, 9.7 % would strongly advise against pregnancy and 4.9 % would suggest a cesarean section with a sterilization procedure. With a history of previous pelvic organ prolapse surgery (POP), 54.4 % would suggest a CS when pregnant, 21.4 % would strongly advise against pregnancy and only 15.5 % would allow the patient to deliver vaginally. Urogynaecologists are significantly more likely to strongly advise a patient with a previous MUS against pregnancy, compared to their peers practicing general obstetrics and gynaecology (OBGYN) (p = 0.04) or maternal fetal medicine (MFM) (p = 0.05). Larger studies and clear guidelines advising physicians to the optimum mode of delivery following a history of previous pelvic floor surgery are strongly needed.

Objective This guideline reviews the evidence related to the risks and benefits of using transvaginal mesh in pelvic organ prolapse repairs in order to update recommendations initially made in 2011. Intended Users Gynaecologists, residents, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with pelvic organ prolapse. Target Population Adult women with symptomatic pelvic organ prolapse considering surgery and those who have previously undergone transvaginal mesh procedures for the treatment of pelvic organ prolapse. Options The discussion relates to transvaginal mesh procedures compared with other surgical options for pelvic organ prolapse (mainly about vaginal native tissue repairs and minimally about other alternatives such as biological and absorbable vaginal mesh and abdominally placed surgical mesh). Outcomes The outcomes of interest are objective and subjective success rates and intraoperative and postoperative complications, such as adjacent organ injury (urinary, gastrointestinal), infection, hematoma/bleeding, vaginal mesh exposure, persistent pain, dyspareunia, de novo stress urinary incontinence, and reoperation. Evidence PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words pelvic organ prolapse/surgery*, prolapse/surgery*, surgical mesh, surgical mesh*/adverse effects, transvaginal mesh, and pelvic organ prolapse. Results were restricted to English or French language and human research. Articles obtained through this search strategy were included until the end of June 2016. Pertinent new studies were added up to September 2016. Grey literature was not searched. Clinical practice guidelines and guidelines of specialty societies were reviewed. Systematic reviews were included when available. Randomized controlled trials and observational studies were included when evidence for the outcome of interest or in the target population was not available from systematic reviews. New studies not yet included in systematic reviews were also included. Only publications with study groups larger than 20 individuals were selected because this criterion was used in the largest meta-analysis referenced in this guideline. A total of 1470 studies were obtained; after selecting only applicable studies and excluding duplicates, 68 manuscripts were reviewed and included. Values The content and recommendations were drafted and agreed upon by the principal authors and members of the Urogynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. The Summary of Findings is available upon request. Benefits, Harms, and/or Costs It is expected that this guideline will benefit women with pelvic organ prolapse by ensuring that health care providers are aware of outcomes related to transvaginal mesh procedures and steps in the management of related complications. This should guide patient-informed consent before such procedures are undertaken. The benefits clearly outweigh the potential harms or costs of implementation of this guideline, although no direct harms or costs are identified. Guideline Update Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. Summary Statements 1.Compared with other non-absorbable synthetic graft materials for use in vaginal prolapse repair, polypropylene type I monofilament, macroporous synthetic mesh is associated with lower complication rates (low). 2.Transvaginal mesh repairs using trocar-guided systems or self-tailored mesh have resulted in lower anatomical prolapse recurrence and marginally reduced symptoms of bulge compared with native tissue repairs. However, quality of life does not seem to differ between transvaginal mesh and native tissue repairs. Anatomical benefit is mostly observed when mesh is used in the anterior compartment. Outcomes of multicompartment transvaginal mesh placement are inconsistent. Transvaginal mesh repair for posterior vaginal wall prolapse is not superior to native tissue repair (low). 3.Transvaginal mesh repairs using trocar-guided systems or self-tailored mesh result in a risk of vaginal mesh exposure averaging 12%, with the lowest risk being in the anterior compartment (compared with multicompartment placement) (moderate). 4.The most significant risk factors for mesh exposure include concomitant hysterectomy and current smoking (low). 5.Preoperative low-dose vaginal estrogen in postmenopausal women does not appear to reduce mesh exposures (moderate). 6.The de novo dyspareunia rate after transvaginal mesh procedures with trocar-guided systems or self-tailored mesh is comparable to native tissue repairs. The risk of non-sexual pelvic, vaginal, buttock, or groin pain is increased (low). 7.The improved anatomical success rate of transvaginal mesh repairs with trocar-guided systems and self-tailored mesh is associated with an increased overall reoperation rate compared with native tissue repairs. The main indications for reoperation after transvaginal mesh procedures include prolapse recurrence, mesh exposure, de novo stress urinary incontinence, and pain (moderate). 8.Evidence for currently commercially available trocarless transvaginal mesh systems is so far limited to observational studies, but outcomes appear to be similar to or better than those obtained with trocar-guided systems (very low). 9.If mesh exposures are small or asymptomatic, an attempt at conservative management is possible. Only one third of women will be cured with this approach. Most will require surgical management (low). 10.Of those who undergo surgery for complications of transvaginal mesh procedures, the cure rate will depend on the nature of the complication. Many with mesh exposure will be cured. Some women will require more than 1 surgery for symptom improvement. Complications such as chronic pain may not be curable (very low). Recommendations 1.Training specific to transvaginal mesh procedures, such as via subspecialty urogynaecology training or individual mentorship programs, should be undertaken before transvaginal mesh procedures are performed (strong, very low). 2.Placement of transvaginal mesh in the rectovaginal space after rectal injury is not recommended (weak, low). 3.Clinically significant preoperative chronic pelvic pain is a relative contraindication to the placement of permanent transvaginal mesh. Pain can worsen postoperatively, and surgical revision to relieve pain is more likely to fail in these patients (strong, very low). 4.Patient selection for permanent polypropylene transvaginal mesh procedures should be further researched. Use of transvaginal mesh procedures outside of clinical trials should be limited to cases with significant risk factors for recurrence (such as levator avulsion, weak pelvic floor muscles, prolapse stage 3 or 4 before index surgery, and chronic strain on the pelvic floor [e.g., chronic constipation]) or for treatment of recurrent pelvic organ prolapse (strong, very low). 5.To assist women in making informed decisions regarding transvaginal mesh procedures, clinicians should provide thorough preoperative counselling. Counselling should include a discussion about (1) improved anatomical outcomes, (2) marginal expected improvement in bulge symptoms, (3) insufficient evidence for improvement in quality of life, (4) risk of mesh exposure and non-sexual pain, and (5) possible need for reoperations compared with native tissue repair (strong, moderate). 6.Patients should be counselled about smoking cessation prior to undergoing transvaginal mesh repair (strong, very low). 7.Informed consent should be clearly documented in the patient's records (strong, very low). 8.Patients who experience complications from a transvaginal mesh repair should be promptly assessed and managed by surgeons who are experienced in dealing with those complications (strong, very low).

Resume Objectif Passer en revue l'utilisation, l'entretien et l'ajustement des pessaires. Options Les pessaires constituent une option pour les femmes qui presentent un prolapsus et/ou une incontinence urinaire. Issues Les pessaires peuvent etre adaptes avec succes a l'anatomie de la majorite des femmes, le tout s'accompagnant de complications minimales et d'excellents taux de satisfaction. Resultats Des recherches ont ete menees dans PubMed et Medline afin d'en tirer les articles publies en anglais, jusqu'en septembre 2010, au moyen des mots cles suivants : « pessary », « prolapse », « incontinence », « fitting », « complications ». Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en mai 2012. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs. Les recommandations ont ete classees conformement a la methode decrite par le Groupe d'etude (Tableau 1). Avantages, desavantages et couts Les femmes peuvent choisir d'avoir recours a un pessaire pour la prise en charge de leur prolapsus et/ou de leur incontinence a l'effort, plutot que de se tourner vers la chirurgie. Des complications majeures n'ont ete constatees qu'en presence de pessaires negliges. Les complications mineures (telles que l'ecoulement, les odeurs et les erosions affectant le vagin) peuvent habituellement etre prises en charge avec succes. Declarations sommaires et recommandation 1.Un pessaire peut etre ajuste avec succes chez la plupart des femmes qui presentent un prolapsus. (II-2) 2.Les complications sont habituellement mineures et la presence d'ecoulements vaginaux constitue la plainte la plus courante. (II-3) 3.Les erosions vaginales peuvent etre traitees au moyen du retrait du pessaire et de la mise en œuvre optionnelle d'une supplementation en oestrogenes par voie vaginale. (II-2) 4.L'utilisation d'un pessaire compte des taux de satisfaction tres eleves. (II-2) 1.L'utilisation d'un pessaire devrait etre envisagee chez toutes les femmes qui presentent un prolapsus symptomatique et/ou une incontinence urinaire a l'effort. (II-1A)

Objective To provide guidelines for pharmacotherapy to treat overactive bladder syndrome (OAB). Options Pharmacotherapy for OAB includes anticholinergic (antimuscarinic) drugs and vaginal estrogen. Both oral and transdermal anticholinergic preparations are available. Outcomes To provide understanding of current available evidence concerning safety and clinical efficacy of pharmacotherapy for OAB; to guide selection of anticholinergic therapy based on individual patient characteristics. Evidence The Cochrane Library and Medline were searched for articles published from 1950 to the present related to individual anticholinergic drugs. Review articles on management of refractory OAB were also examined. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to 2010. Values The quality of evidence is rated and recommendations are made using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs Anticholinergics are the mainstay of pharmacotherapy for OAB. Evidence for their efficacy is mostly derived from short-term phase III randomized drug trials. Placebo response is strong, and long-term follow-up and patient subjective outcome data are lacking. Care providers need to be well acquainted with the side effects of anticholinergics and select therapy based on individual patient parameters. Recommendations 1.Behavioural management protocols and functional electrical stimulation should be offered in the spectrum of effective primary treatments for overactive bladder syndrome. (I-A) 2.Oral oxybutynin, immediate and extended release, as well as transdermal oxybutynin, may be offered as treatment for overactive bladder syndrome, as they are associated with significant objective clinical improvement at 12 weeks. (I-A) Oxybutynin immediate release has superior cost-effectiveness but more side effects than other anticholinergics. (I-A) Adverse events associated with transdermal oxybutynin are fewer than with oral oxybutynin. (I-A) 3.Tolterodine, immediate and extended release, may be offered as treatment for overactive bladder syndrome, as it is associated with significant objective clinical improvement at 12 weeks. (I-A) 4.Trospium, immediate and extended release, may be offered as treatment for overactive bladder syndrome as it is associated with significant clinical improvement at 12 weeks. (I-A) Trospium is an adequate anticholinergic choice for overactive bladder syndrome patients with pre-existing cognitive impairment (II-B) and for overactive bladder syndrome patients taking concurrent CYP450 inhibitors. (III-B) 5.Solifenacin may be offered as treatment for overactive bladder syndrome, as it is associated with significant objective clinical improvement at 12 weeks. (I-A) Solifenacin may be an adequate anticholinergic choice for elderly overactive bladder syndrome patients or patients with pre-existing cognitive dysfunction. (I-B) 6.Darifenacin may be offered as treatment for overactive bladder syndrome, as it is associated with significant objective clinical improvement at 12 weeks. (I-A) Darifenacin is an adequate anticholinergic choice for overactive bladder syndrome patients with pre-existing cardiac concerns or cognitive dysfunction. (I-B) 7.Overactive bladder syndrome patients should be offered a choice between bladder training, functional electric stimulation, and anticholinergic therapy, as there is no difference in cure rates. Combination therapy does not have a clear advantage over one therapy alone. (I-A) 8.The choice of anticholinergic therapy should be guided by individual patient comorbidities, as objective efficacy of anticholinergic drugs is similar. (I-A) Dose escalation does not improve objective parameters and causes more anticholinergic adverse effects. It is, however, associated with improved subjective outcomes. (I-A) To decrease side effects, switching to a lower dose or using an extended release formulation or a transdermal delivery mechanism should be considered. (I-A) 9.Education on treatment efficacy, realistic expectations, and length of treatment should be offered to patients upon initiation of anticholinergic therapy, as continuation rates for anticholinergic therapy are low. (III-B) 10.Oral or transdermal estrogen supplementation should not be recommended for treatment of overactive bladder syndrome as its effects are comparable to placebo. (I-E) Vaginal estrogen can be suggested for subjective improvements in overactive bladder syndrome symptoms. (III-B) 11.Intravesical botulinum toxin injection and sacral nerve and posterior tibial nerve stimulation are clinically effective options for patients with overactive bladder syndrome unresponsive to conservative options, anticholinergics, or vaginal estrogen. (I-A)

Objective To provide an update on transvaginal mesh procedures, newly available minimally invasive surgical techniques for pelvic floor repair Options The discussion is limited to minimally invasive transvaginal mesh procedures. Evidence PubMed and Medline were searched for articles published in English, using the key words "pelvic organ prolapse," transvaginal mesh," and "minimally invasive surgery." Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis, and articles were incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1). Benefits, harms, and costs Counselling for the surgical treatment of pelvic organ prolapse should consider all benefits, harms, and costs of the surgical procedure, with particular emphasis on the use of mesh. Recommendations 1.Patients should be counselled that transvaginal mesh procedures are considered novel techniques for pelvic floor repair that demonstrate high rates of anatomical cure in uncontrolled short-term case series. (II-2B) 2.Patients should be informed of the range of success rates until stronger evidence of superiority is published. (II-2B) 3.Training specific to transvaginal mesh procedures should be undertaken before procedures are performed. (III-C) 4.Patients should undergo thorough preoperative ounselling regarding (a) the potential serious adverse sequelae of transvaginal mesh repairs, including mesh exposure, pain, and dyspareunia; and (b) the limited data available comparing transvaginal mesh systems with traditional vaginal prolapse repairs or with traditional use of graft material in the form of augmented colporrhaphy and sacral colpopexy. (III-C) 5.Until appropriate supportive data are available, new trocarless kits should be considered investigative. (III-C)

Resume Objectif Fournir une mise a jour sur les interventions de treillis transvaginales (techniques chirurgicales a effraction minimale nouvellement disponibles visant la reparation du plancher pelvien). Options La discussion est limitee aux interventions de treillis transvaginales a effraction minimale. Resultats Des recherches ont ete menees dans PubMed et Medline en vue d'en tirer des articles publies en anglais, au moyen des mots cles « pelvic organ prolapse », « transvaginal mesh » et « minimally invasive surgery ». Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les recherches ont ete mises a jour de facon reguliere et leurs resultats ont ete incorpores a la directive clinique jusqu'en mai 2010. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete etablie au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs. Les recommandations visant la pratique ont ete classees conformement a la methode decrite dans ce rapport (Tableau 1). Avantages, desavantages et couts Le counseling visant la prise en charge chirurgicale du prolapsus des organes pelviens devrait prendre en consideration tous les avantages, les desavantages et les couts de l'intervention chirurgicale, en insistant particulierement sur l'utilisation du treillis. Recommendations 1.Les patientes devraient etre avisees que les interventions de treillis transvaginales sont considerees comme des techniques novatrices visant la reparation du plancher pelvien qui ont permis l'obtention de taux eleves de cure anatomique dans le cadre de series de cas a court terme non comparatives. (II-2B) 2.Les patientes devraient etre avisees de la plage des taux de reussite jusqu'a ce que des donnees etablissant mieux la superiorite de ces techniques soient publiees. (II-2B) 3.Une formation traitant particulierement des interventions de treillis transvaginales devrait etre mise en oeuvre avant la tenue de telles interventions. (III-C) 4.Les patientes devraient se soumettre a un counseling preoperatoire exhaustif portant sur (a) les sequelles potentiellement graves des interventions de treillis transvaginales, y compris l'exposition au treillis, la douleur et la dyspareunie; et (b) le caractere limite des donnees disponibles comparant les systemes de treillis transvaginaux aux interventions traditionnelles de reparation du prolapsus vaginal ou a l'utilisation traditionnelle de materiaux de greffon sous forme de colporraphie augmentee et de colpopexie sacree. (III-C) 5.Jusqu'a ce que des donnees de soutien appropriees soient disponibles, l'utilisation des nouvelles trousses « sans trocart » devrait etre consideree comme relevant du domaine de la recherche. (III-C)

Resume Objectif Fournir une mise a jour quant a la definition, a l'epidemiologie, a la presentation clinique, a l'exploration, a la prise en charge et a la prevention des infections recurrentes des voies urinaires chez les femmes. Options L'antibioprophylaxie continue, l'antibioprophylaxie postcoitale et l'autotraitement aigu constituent tous des solutions de rechange efficaces pour la prevention des infections recurrentes des voies urinaires. Les œstrogenes vaginaux et le jus de canneberges peuvent egalement constituer des solutions de rechange prophylactiques efficaces. Resultats Les recherches menees dans PubMed et The Cochrane Library en vue d'en tirer des articles publies en anglais ont permis d'identifier la litterature la plus pertinente. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises /essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction quant a la date n'a ete mise en œuvre. Valeurs La presente mise a jour reflete le consensus dusous-comite sur l'urogynecologie de la Societe des obstetriciens et gynecologues du Canada. Les recommandations ont ete formulees conformement aux criteres etablis par le Groupe d'etude canadien sur les soins de sante preventifs(Tableau 1). Options Les infections recurrentes des voies urinaires necessitent une exploration rigoureuse et peuvent etre efficacement prises en charge et prevenues. Differentes options prophylactiques peuvent etre selectionnees en fonction des caracteristiques de chacune des patientes. Recommandations 1.L'analyse d'urine, la mise en culture d'urine permictionnelle et l'analyse de la sensibilite devraient etre menees des la premiere presentation des symptomes, et ce, afin de pouvoir bien etablir un diagnostic d'infection recurrente des voies urinaires. (III-L) 2.Les patientes qui presentent une hematurie persistante ou une croissance bacterienne persistante (a part Escherichia coli) devraient subir une cystoscopie et une imagerie des voies urinaires superieures. (III-L) 3.Les femmes sexuellement actives qui presentent des infections recurrentes des voies urinaires et qui utilisent un spermicide devraient etre incitees a envisager l'utilisation d'une autre forme de contraception. (II-2B) 4.La prophylaxie de l'infection recurrente des voies urinaires ne devrait pas etre mise en œuvre avant qu'une culture negative (menee d'une a deux semaines a la suite du traitement) n'ait confirme l'eradication de l'infection des voies urinaires. (III-L) 5.Une antibioprophylaxie quotidienne continue (faisant appel au cotrimoxazole, a la nitrofurantoine, a la cephalexine, au trimethoprime, au trimethoprime-sulfamethoxazole, ou a une quinolone) mise en œuvre pendant une periode de six a 12 mois devrait etre offerte aux femmes qui ont presente ≥ 2 infections des voies urinaires en 6 mois ou ≥ 3 infections des voies urinaires en 12 mois. (I-A) 6.Les femmes qui presentent une infection recurrente des voies urinaires associee aux relations sexuelles devraient se voir offrir une prophylaxie postcoitale a titre de solution de rechange au traitement continu, et ce, afin de minimiser les couts et les effets indesirables. (I-A) 7.L'autotraitement aigu devrait etre restreint aux patientes respectant les consignes et motivees chez lesquelles des infections recurrentes des voies urinaires ont ete clairement documentees. (I-B) 8.Des œstrogenes vaginaux devraient etre offerts aux femmes postmenopausees qui connaissent des infections recurrentes des voies urinaires. (I-A) 9.Les patientes devraient etre avisees de l'efficacite des produits de canneberges pour ce qui est de l'attenuation des infections recurrentes des voies urinaires. (I-A) 10.L'acupuncture peut etre envisagee a titre de solution de rechange dans la prevention des infections recurrentes des voies urinaires chez les femmes qui ne reagissent pas a l'antibioprophylaxie ou qui y sont intolerantes. (I-B) 11.Les probiotiques et les vaccins ne peuvent etre offerts a titre de traitement eprouve contre l'infection recurrente des voies urinaires. (II-2C) 12.Les femmes enceintes exposees a des risques d'infection recurrente des voies urinaires devraient se voir offrir une prophylaxie continue ou postcoitale faisant appel a la nitrofurantoine ou a la cephalexine, sauf au cours des quatre derniers mois de grossesse. (II-1B)

Objective To provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women. Options Continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives. Evidence A search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. Values This update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). Options Recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patient's characteristics. Recommandations 1.Urinalysis and midstream urine culture and sensitivity should be performed with the first presentation of symptoms in order to establish a correct diagnosis of recurrent urinary tract infection. (III-L) 2.Patients with persistent hematuria or persistent growth of bacteria aside from Escherichia coli should undergo cystoscopy and imaging of the upper urinary tract. (III-L) 3.Sexually active women suffering from recurrent urinary tract infections and using spermicide should be encouraged to consider an alternative form of contraception. (II-2B) 4.Prophylaxis for recurrent urinary tract infection should not be undertaken until a negative culture 1 to 2 weeks after treatment has confirmed eradication of the urinary tract infection. (III-L) 5.Continuous daily antibiotic prophylaxis using cotrimoxazole, nitrofurantoin, cephalexin, trimethoprim, trimethoprim-sulfamethoxazole, or a quinolone during a 6-to 12-month period should be offered to women with ≥ 2 urinary tract infections in 6 months or ≥ 3 urinary tract infections in 12 months. (I-A) 6.Women with recurrent urinary tract infection associated with sexual intercourse should be offered post-coital prophylaxis as an alternative to continuous therapy in order to minimize cost and side effects. (I-A) 7.Acute self-treatment should be restricted to compliant and motivated patients in whom recurrent urinary tract infections have been clearly documented. (I-B) 8.Vaginal estrogen should be offered to postmenopausal women who experience recurrent urinary tract infections. (I-A) 9.Patients should be informed that cranberry products are effective in reducing recurrent urinary tract infections. (I-A) 10.Acupuncture may be considered as an alternative in the prevention of recurrent urinary tract infections in women who are unresponsive to or intolerant of antibiotic prophylaxis. (I-B) 11.Probiotics and vaccines cannot be offered as proven therapy for recurrent urinary tract infection. (II-2C) 12.Pregnant women at risk of recurrent urinary tract infection should be offered continuous or post-coital prophylaxis with nitrofurantoin or cephalexin, except during the last 4 weeks of pregnancy. (II-1B)

Resume Objectif Fournir aux gynecologues generalistes et aux urogynecologues une directive clinique sur la prise en charge de l'incontinence urinaire recurrente a la suite d'une chirurgie visant le plancher pelvien. Options L'evaluation englobe les antecedents et l'examen physique, l'urodynamique multicanal et, peut-etre, l'uretrocystoscopie. La prise en charge couvre les interventions conservatrices, pharmacologiques et chirurgicales. Issue La presente directive clinique offre une approche exhaustive quant a la problematique complexe de l'incontinence recurrente qui est fondee sur les mecanismes pathophysiologiques sous-jacents. Resultat Les opinions publiees par des specialistes et les resultats d'essais cliniques, le cas echeant. Valurs La qualite des resultats a ete evaluee au moyen des criteres decrits par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau). Recommandations 1.Chaque patiente devrait faire l'objet d'une evaluation exhaustive visant a determiner l'etiologie sous-jacente de l'incontinence urinaire recurrente et a orienter la prise en charge. (II-3B) 2.Les options de prise en charge conservatrice devraient etre utilisees a titre de traitements de premiere intention. (III-C) 3.Les patientes qui presentent un uretre hypermobile, en l'absence de signes d'insuffisance du sphincter intrinseque, peuvent etre prises en charge au moyen d'une uretropexie retropubienne (p. ex. intervention de Burch) ou d'une intervention de bandelette (p. ex. bandelette mi-uretrale, bandelette pubovaginale). (II-2B) 4.Les patientes qui presentent des signes d'insuffisance du sphincter intrinseque peuvent etre prises en charge au moyen d'une intervention de bandelette (p. ex. bandelette mi-uretrale, bandelette pubovaginale). (II-3B) 5.Dans les cas d'intervention chirurgicale visant l'insuffisance du sphincter intrinseque, l'utilisation d'une bandelette vaginale retropubienne devrait etre privilegiee a celle d'une bandelette transobturatrice. (I-B) 6.Les patientes qui presentent une mobilite uretrale considerablement reduite peuvent etre prises en charge au moyen d'injections gonflantes periuretrales, d'une intervention de bandelette retropubienne, de la mise en place d'un sphincter artificiel, d'un detournement urinaire ou d'un catheterisme chronique. (III-C) 7.La vessie hyperactive devrait etre prise en charge au moyen d'un traitement medical et/ou comportemental. (II-2B) 8.La pollakiurie s'accompagnant d'une hausse moderee du volume du residu post-mictionnel peut etre prise en charge au moyen de mesures conservatrices, telles que l'administration de medicaments visant a detendre le sphincter uretral, la miction a intervalles determines et la miction double. L'auto-catheterisme intermittent peut egalement etre mis en œuvre. (III-C) 9.L'incapacite totale de proceder a la miction, avec ou sans incontinence par regorgement, peut etre prise en charge au moyen d'un auto-catheterisme intermittent ou d'une uretrolyse. (III-C) 10.Les fistules devraient etre prises en charge par un medecin experimente. (III-C)

Objective To provide general gynaecologists and urogynaecologists with clinical guidelines for the management of recurrent urinary incontinence after pelvic floor surgery. Options Evaluation includes history and physical examination, multichannel urodynamics, and possibly cystourethroscopy. Management includes conservative, pharmacological, and surgical interventions. Outcomes These guidelines provide a comprehensive approach to the complicated issue of recurrent incontinence that is based on the underlying pathophysiological mechanisms. Evidence Published opinions of experts, and evidence from clinical trials where available. Values The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). Recommendations 1.Thorough evaluation of each patient should be performed to determine the underlying etiology of recurrent urinary incontinence and to guide management (II-3B). 2.Conservative management options should be used as the first line of therapy (III-C). 3.Patients with a hypermobile urethra, without evidence of intrinsic sphincter deficiency, may be managed with a retropubic urethropexy (e.g., Burch procedure) or a sling procedure (e.g., mid-urethral sling, pubovaginal sling) (II-2B). 4.Patients with evidence of intrinsic sphincter deficiency may be managed with a sling procedure (e.g., mid-urethral sling, pubovaginal sling) (II-3B). 5.In cases of surgical treatment of intrinsic sphincter deficiency, retropubic tension-free vaginal tape should be considered rather than transobturator tape (I-B). 6.Patients with significantly decreased urethral mobility may be managed with periurethral bulking injections, a retropubic sling procedure, use of an artificial sphincter, urinary diversion, or chronic catheterization (III-C). 7.Overactive bladder should be treated using medical and/or behavioural therapy (II-2B). 8.Urinary frequency with moderate elevation of post-void residual volume may be managed with conservative measures such as drugs to relax the urethral sphincter, timed toileting, and double voiding. Intermittent self-catheterization may also be used (III-C). 9.Complete inability to void with or without overflow incontinence may be managed by intermittent self-catheterization or urethrolysis (III-C). 10.Fistulae should be managed by an experienced physician (III-C).

Objective To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS. Options Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies. Outcomes The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth. Evidence Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth

Peri-urethral bulking agents are used as a management option for selected patients with stress urinary incontinence (SUI). We present a case of urinary retention and a large firm para-urethral vaginal mass as a complication of peri-urethral collagen injections 3 years before presentation. The patient was managed successfully with complete surgical resection of the mass. Subsequent recurrent SUI was managed using a rectus fascial sling.

Objective To review the use, care, and fitting of pessaries. Options Pessaries are an option for women presenting with prolapse and/or urinary incontinence. Outcomes Pessaries can be successfully fitted in the majority of women with excellent satisfaction rates and minimal complications. Evidence PubMed and Medline were searched for articles published in English to September 2010, using the key words pessary, prolapse, incontinence, fitting, and complications. Results were restricted to systematic reviews, randomized control trials/ controlled clinical trials, and observational studies. Searches were updated on a regular basis, and articles were incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force (Table 1). Benefits, harms, and costs Women may choose a pessary for management of their prolapse and/or stress incontinence rather than opt for surgery. Major complications have been seen only with neglected pessaries. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated.

To provide an update on transvaginal mesh procedures, newly available minimally invasive surgical techniques for pelvic floor repair.The discussion is limited to minimally invasive transvaginal mesh procedures.PubMed and Medline were searched for articles published in English, using the key words "pelvic organ prolapse," transvaginal mesh," and "minimally invasive surgery." Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis, and articles were incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1).Counselling for the surgical treatment of pelvic organ prolapse should consider all benefits, harms, and costs of the surgical procedure, with particular emphasis on the use of mesh.1. Patients should be counselled that transvaginal mesh procedures are considered novel techniques for pelvic floor repair that demonstrate high rates of anatomical cure in uncontrolled short-term case series. (II-2B) 2. Patients should be informed of the range of success rates until stronger evidence of superiority is published. (II-2B) 3. Training specific to transvaginal mesh procedures should be undertaken before procedures are performed. (III-C) 4. Patients should undergo thorough preoperative counselling regarding (a) the potential serious adverse sequelae of transvaginal mesh repairs, including mesh exposure, pain, and dyspareunia; and (b) the limited data available comparing transvaginal mesh systems with traditional vaginal prolapse repairs or with traditional use of graft material in the form of augmented colporrhaphy and sacral colpopexy. (III-C) 5. Until appropriate supportive data are available, new trocarless kits should be considered investigative. (III-C).