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This single-blind, randomised controlled trial was aimed at determining whether peri-operative physiotherapist-supervised pelvic floor muscle (PFM) training was superior to standard care (handout) in terms of improvements in stress urinary incontinence (SUI) symptoms, cure rate, and/or post-operative filling or voiding symptoms among women undergoing surgical mid-urethral sling (MUS) insertion for SUI. Women with SUI were recruited from surgical wait lists at four participating urogynecology clinics. Participants were assessed at baseline (V1) then randomised (1:1 allocation) to receive supervised PFM training or a handout. Immediately following the 12-week intervention period (V2) and at 12 weeks following surgery (V3) the groups were compared based on the Female Lower Urinary Tract Symptoms (FLUTS) questionnaire total score and urinary incontinence, filling, and voiding subscale scores as well as on a standardised 30-min pad test administered by a blinded assessor. Intention-to-treat analyses were performed. A total of 52 participants were randomised to physiotherapy and 51 to the control group between December 2012 and August 2016. The groups were not different on any outcomes at V1 and all were improved at V3 compared with V1 (p 0.05). Based on a FLUTS UI subscale score 0.05). No adverse events were reported. Physiotherapist-supervised PFM training improves SUI cure rates associated with surgical MUS insertion when considering symptoms of SUI, but does not improve post-operative continence function as measured by a pad test, nor does it lead to fewer post-operative voiding or filling symptoms.

Menstrual abnormalities and shortened reproductive lifespan are associated with shorter life expectancy and higher cardiovascular and osteoporosis risk in the general population, although the magnitude of these reproductive factor irregularities in females with CKD is unclear. This systematic review and meta-analysis aimed to summarize the current knowledge regarding menstrual abnormalities and reproductive lifespan among females with CKD.A comprehensive bibliographic search (MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) was completed from database inception to February 2022 to identify all original articles reporting on females of reproductive age with nondialysis-dependent/nonkidney transplant CKD, dialysis-dependent CKD, or kidney transplantation and menstruation patterns, age of menarche, and/or menopause. Data extraction and study quality assessment were completed in duplicate. Random effects meta-analyses were used to derive pooled proportions estimates.Forty-six studies were identified, and 35 were meta-analyzed, stratified by KRT modality and reported outcome. Menstrual abnormalities were present in 19%-47% of patients on hemodialysis and 75% of patients on peritoneal dialysis. Kidney transplantation was associated with a 7%-30% decrease in menstrual abnormalities. Reproductive lifespan was 32 years (95% confidence interval, 30 to 34 years). Although significant heterogeneity was present, study quality ranged from fair to good, and no evidence of publication bias was noted.Menstrual abnormalities and shorter reproductive lifespan are common in females with CKD, although kidney transplantation may improve menstrual health.

Although guaranteed by the GDPR, transparency of health data processing may not be fully respected, leading citizens to mistrust eHealth and discard digital health services. Identifying and safeguarding ethics in eHealth services is thus important to promote their development. We conducted a survey to assess the extent of ethical issues induced by the use of digital health services, understand the efforts citizens would be willing to accept for reporting such issues, and evaluate citizens' expectations regarding this reporting. Among 200 respondents, 36% reported having encountered ethical issues with the processing of their health data or with digital health services being poorly inclusive. Faced to ethical issues when using a digital health service, 49% of respondents were rather or very angry, and 33% felt rather or very dependent. Most respondents were ready to report digital health ethical issues if there is a feedback for each report.

Introduction and hypothesis The aim of this study was to prospectively identify aspects of baseline demographic, clinical, and pelvic morphology of women with stress urinary incontinence (SUI) that are predictive of cure with physiotherapist-supervised pelvic floor muscle training (PFMT). Methods Women ≥18 years old with SUI were recruited from urogynecology and pelvic health physiotherapy clinics. Participants completed a 3-day bladder diary, the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF), a standardized pad test, manual assessment of pelvic floor muscle (PFM) strength and tone, and transperineal ultrasound (TPUS) assessment of their urogenital structures at rest while in a supine position and standing, and during contraction, straining, and coughing. Participants attended six physiotherapy sessions over 12 weeks and performed a home PFMT program. The assessment was repeated after the intervention; cure was defined as a dry (≤2 g) pad test. Results Seventy-seven women aged 50 (±10) years completed the protocol; 38 (49%) were deemed cured. Based on univariate testing, four predictors were entered into a binary logistic regression model: ICIQ-UI-SF, PFM tone, bladder neck (BN) height in a quiet standing position, and BN height during a cough in a standing position. The model was significant (p p = 0.00), and with 70% sensitivity and 75% specificity. Conclusions Women with better bladder support in a standing position and less severe symptoms were most likely to be cured with PFMT. Clinical trial registration #NCT01602107.

This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.

The goal of this study was to determine the prevalence of urinary incontinence among female university varsity rugby players. Secondary objectives were to understand when the incontinence occurred and to assess the degree of bother experienced. It is postulated that female rugby players may have higher rates of urinary incontinence due to the high-impact activities involved in training and competitions. Data was collected via a self-administered, anonymous questionnaire. A total of 95 athletes were included in the survey results. Urinary incontinence was experienced by 51 of the 95 (54%) players. Of the 51 athletes who reported leaking urine, 90% leaked urine when competing in a rugby game and 88% of players leaked when being tackled or hit. Despite the high prevalence of urinary incontinence, most players reported they were not bothered or only slightly bothered by their urinary leaking. Several of the players (18%) were interested in receiving treatment for their urinary incontinence. The prevalence of urinary incontinence among varsity female rugby players is 54%, which is consistent with rates among other high-impact sports. Surprisingly, the majority of these women are not bothered by their incontinence and most are not interested in treatment for this condition at this time.

Two techniques to set the tension of retropubic midurethral slings provide similar rates of cure but different rates of obstruction, bladder overactivity, and mesh erosion., OBJECTIVE: To evaluate whether the use of a Mayo Scissor as a suburethral spacer compared with a Babcock clamp holding a loop of tape under the urethra results in different rates of abnormal bladder outcomes 12 months after retropubic midurethral sling surgery. METHODS: The MUST (Mid-Urethral Sling Tensioning) trial was a block-randomized, double-blind, multicenter clinical trial that allocated women to have their retropubic midurethral slings tensioned by Scissor or Babcock technique. The primary outcome (abnormal bladder) was a composite of persistent stress urinary incontinence (SUI), overactive bladder, and urinary retention. Secondary outcomes included outcomes of the composite, postoperative catheterization, incontinence-related questionnaires, repeat incontinence treatment, and uroflowmetry. Sample size of 159 in each arm (N=318) was planned for a superiority trial, hypothesizing a 10% difference in primary outcome. RESULTS: From September 2015 to December 2017, 506 women were screened and 318 were randomized. Baseline characteristics were similar in each arm. At 12 months, 253 (79.6%) women provided information on primary outcome: 40 of 128 (31.3%) patients with midurethral slings tensioned by Scissor experienced abnormal bladder, compared with 23 of 125 (18.4%) of those with midurethral slings tensioned by Babcock (P=.018, relative difference 12.9%). Secondary analyses favored Babcock for median duration of catheterization and the proportions of women experiencing urinary retention requiring sling lysis. Uroflowmetry parameters suggest the Scissor technique is more restrictive. Rates of mesh erosion were lower for the Scissor arm. No differences occurred in proportions of women experiencing patient reported persistent SUI after surgery. CONCLUSION: Abnormal bladder outcomes were 12.9% less frequent for women with midurethral slings tensioned by Babcock. Both techniques provided a comparable patient reported cure for SUI at 12 months. Women with midurethral slings tensioned by Scissors experienced more intervention for obstruction, whereas those with midurethral slings tensioned by Babcock experienced higher rates of mesh erosion. This information about how the postoperative courses differ allows surgeons to better counsel patients preoperatively or tailor their choice of technique. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02480231. FUNDING SOURCE: Boston Scientific.

This article provides a detailed account of how surgeons perceived and used a device-procedure that caused widespread patient harm: transvaginal mesh for the treatment of pelvic floor disorders in women. Drawing from interviews with 27 surgeons in Canada, the UK, the United States and France and observations of major international medical conferences in North America and Europe between 2015 and 2018, we describe the commercially driven array of operative variations in the use of transvaginal mesh and show that surgeons' understanding of their hands-on, sensory experience with these variations is central to explaining patient harm. Surgeons often developed preferences for how to manage actual and anticipated dangers of transvaginal mesh procedures through embodied operative adjustments, but collectively the meaning of these preferences was fragmented, contested and deferred. We critically reflect on surgeons' understandings of their operative experience, including the view that such experience is not evidence. The harm in this case poses a challenge to some ways of thinking about uncertainty and errors in medical sociology, and calls for attention to a specific feature of surgical work: the extent and persistence of operative practices that elude classification as right or wrong but are still most certainly better and worse.

This study aimed to review the literature to establish the prevalence of pelvic floor disorders in the fibromyalgia population. A systematic literature search through computerized databases including PubMed and EMBASE was completed using medical subject heading (MeSH) terms from January 1, 1990 to November 1, 2017. Articles were included if the focus was prevalence of pelvic floor disorders in the population of persons with fibromyalgia. To provide consistency of diagnosis, use of the American College of Rheumatology 1990 or 2010 criteria was required. Evidence was graded according to Canadian Task Force on Preventive Health Care and Newcastle-Ottawa quality assessment scales. A total of 11 studies were deemed eligible for inclusion from 1024 articles initially identified. Only one study used the most recent 2010 American College of Rheumatology diagnostic criteria. There was significant heterogeneity in the reporting of fibromyalgia populations. Outcomes reported were variable and not consistent across studies; thus, data could not be pooled. There appears to be a high prevalence of gastrointestinal, genitourinary, and gynaecological dysfunction. In case-control studies, these dysfunctions appeared to be more prevalent in the fibromyalgia group than in the control populations. However, this difference could not be quantified more specifically. In conclusion, the small number of eligible studies and the variety of pelvic floor outcomes reported limited formation of conclusive prevalence of pelvic floor disorders in the fibromyalgia population. From the small number of studied patients, there may be a higher prevalence of gastrointestinal, genitourinary, and gynaecological concerns in women with fibromyalgia.

This single-blind, randomised controlled trial was aimed at determining whether peri-operative physiotherapist-supervised pelvic floor muscle (PFM) training was superior to standard care (handout) in terms of improvements in stress urinary incontinence (SUI) symptoms, cure rate, and/or post-operative filling or voiding symptoms among women undergoing surgical mid-urethral sling (MUS) insertion for SUI.Women with SUI were recruited from surgical wait lists at four participating urogynecology clinics. Participants were assessed at baseline (V1) then randomised (1:1 allocation) to receive supervised PFM training or a handout. Immediately following the 12-week intervention period (V2) and at 12 weeks following surgery (V3) the groups were compared based on the Female Lower Urinary Tract Symptoms (FLUTS) questionnaire total score and urinary incontinence, filling, and voiding subscale scores as well as on a standardised 30-min pad test administered by a blinded assessor. Intention-to-treat analyses were performed.A total of 52 participants were randomised to physiotherapy and 51 to the control group between December 2012 and August 2016. The groups were not different on any outcomes at V1 and all were improved at V3 compared with V1 (p 0.001). At V3 the physiotherapy group reported significantly fewer UI symptoms (FLUTS UI subscale score) than the control group; yet, there were no group differences in FLUTS overall score or the pad test (p 0.05). Based on a FLUTS UI subscale score 4, the cure rate at V3 was higher in the intervention group (73%) than in the control group (47%); (2.36 OR 3.47, p = 0.012). There were no group differences in cure rate at V3 based on a pad test (p = 0.27). No group differences were found in the filling or voiding symptoms at V3 (p 0.05). No adverse events were reported.Physiotherapist-supervised PFM training improves SUI cure rates associated with surgical MUS insertion when considering symptoms of SUI, but does not improve post-operative continence function as measured by a pad test, nor does it lead to fewer post-operative voiding or filling symptoms.

Substance use during pregnancy continues to be an area of concern in Canada. Rates of substance use appear to be increasing among women of childbearing age, and use during pregnancy may effect maternal and fetal outcomes. Little is known of the prevalence of methamphetamine use during pregnancy and its impact, but maternity care providers are encountering patients who use methamphetamines in their practices. These health care providers are asking for evidence-based recommendations for management and treatment. There is an immediate and urgent need to address this gap in order to improve the health of pregnant women and their babies.

Beginning in the late 1990s, surgeons around the world widely adopted the transvaginal placement of permanent synthetic mesh for the treatment of several common pelvic floor disorders in women. By 2012 it had become the subject of extensive litigation, including one of the biggest mass-tort cases in U.S. history, with litigants reporting debilitating and unexpected complications. Based on qualitative research that includes interviews with surgeons, observations of medical conferences, and analysis of archival materials, we argue the adoption of transvaginal mesh cannot be fully explained without recognizing the role of mindlines, or collective moral-epistemological ways of knowing and acting responsibly. The adoption of mesh was anchored in a mindline focused on repairing anatomy. The harms that resulted from transvaginal mesh necessitated a shift to a focus on patient experience. We analyze the role of evidence-based medicine (EBM) in the re-organization of these surgeons' mindlines, showing that mindlines are not reducible to evidence as defined by EBM and that evidence thus defined facilitated the adoption of transvaginal mesh.

OBJECTIVE To investigate the effect of intranasal oxytocin on chronic pelvic pain in a randomized, double-blind, within-subject crossover trial. Aims included: (1) determine intranasal oxytocin's effect on pain intensity and pain interference relative to placebo; (2) assess feasibility and acceptability. METHODS Women with chronic pelvic pain were recruited from chronic pain and gynecology clinics between September 2017 and December 2018. Pain was recorded at pre-trial screening, and while administering intranasal oxytocin and placebo. Pain and pain-related interference were measured using the Brief Pain Inventory - Short Form. Feasibility and acceptability were measured using validated measures and interviews. RESULTS Twenty-one women were randomized with sufficient data available from 12 to permit analyses. Relative to placebo, a 2-week course of oxytocin administration resulted in improvement in pain severity with no effect on pain-related interference. This effect was driven by four women who demonstrated a minimal clinically significant improvement in pain following intranasal oxytocin (no women met this threshold for placebo). Adherence to dosing was excellent and occurrence of adverse effects did not differ between oxytocin and placebo. CONCLUSION Intranasal oxytocin may represent an adjuvant analgesic that could result in a minimal clinically significant improvement in pain among one in three women with chronic pelvic pain. Registration: ClinicalTrials.gov (Registration# NCT02888574).

Aims To report the initial clinical experience with selective bladder denervation (SBD) of the trigone in women with refractory overactive bladder (OAB). Methods Females with refractory OAB underwent SBD of the bladder sub-trigone region. Patients were treated using a 10-s voltage-controlled radiofrequency (RF) algorithm (RF10) at study onset. The protocol was modified during the study after which point remaining patients received 60-s temperature-controlled RF (RF60). Patients were followed for 12 weeks and evaluated for adverse events and changes in OAB symptoms. Exploratory analyses on the influence of RF duration were performed. Results Among 63 patients, SBD resulted in statistically significant and clinically important improvements for most outcomes. Comparing RF10 (n = 34) to RF60 (n = 29), treatment benefit was greater with RF60 including mean reduction in urgency urinary incontinence (-2.5 vs -0.9; P < 0.01), urinary incontinence (-2.6 vs -0.8; P < 0.001), and total urgency and frequency score (-13 vs -7; P = 0.02); and improvements in symptom bother (-33 vs -18; P < 0.01) and quality of life (28 vs 16; P = 0.02) on the OAB questionnaire. The proportion of urgency urinary incontinence treatment responders (>= 50% reduction in episodes) was 79% with RF60 and 31% with RF10. The frequency of device- or procedure-related adverse events was comparable in RF10 versus RF60 groups (14.7% vs 17.2%). Conclusions This study demonstrated the feasibility of SBD in alleviating symptoms of refractory OAB. A 60-s RF algorithm using deeper ablations of the sub-trigonal tissues was more effective and comparably safe to a 10-s RF algorithm using more superficial ablations.

The purpose of the study was to assess safety and efficacy of autologous muscle derived cells for urinary sphincter repair (AMDC-USR) in female subjects with predominant stress urinary incontinence. A randomized, double-blind, multicenter trial examined intra-sphincteric injection of 150 × 106 AMDC-USR versus placebo in female subjects with stress or stress predominant, mixed urinary incontinence. AMDC-USR products were generated from vastus lateralis needle biopsies. Subjects were randomized 2:1 to receive AMDC-USR or placebo and 1:1 to receive 1 or 2 treatments (6 months after the first). Primary outcome was composite of ≥ 50% reduction in stress incontinence episode frequency (IEF), 24-h or in-office pad weight tests at 12 months. Other outcome data included validated subject-recorded questionnaires. Subjects randomized to placebo could elect to receive open-label AMDC-USR treatment after 12 months. Subject follow-up was up to 2 years. AMDC-USR was safe and well-tolerated with no product-related serious adverse events or discontinuations due to adverse events. Interim analysis revealed an unexpectedly high placebo response rate (90%) using the composite primary outcome which prevented assessment of treatment effect as designed and thus enrollment was halted at 61% of planned subjects. Post hoc analyses suggested that more stringent endpoints lowered placebo response rates and revealed a possible treatment effect. Although the primary efficacy finding was inconclusive, these results inform future trial design of AMDC-USR to identify clinically meaningful efficacy endpoints based on IEF reduction, understanding of placebo response rate, and refinement of subject selection criteria to more appropriately align with AMDC-USR’s proposed mechanism of action.

Resume Objectif Decrire les resultats qui sous-tendent les options de prise en charge conservatrice de l'incontinence urinaire. Options Parmi les options de prise en charge conservatrice de l'incontinence urinaire, on trouve les modifications comportementales, la modification du mode de vie, la reeducation du plancher pelvien et le recours a des dispositifs mecaniques. Issues Permettre la comprehension des resultats actuellement disponibles en ce qui concerne l'efficacite des solutions de rechange conservatrices visant la prise en charge de l'incontinence urinaire; habiliter les femmes a choisir des traitements contre l'incontinence comptant des avantages et ne presentant que des desavantages minimaux ou meme inexistants. Resultats Des recherches ont ete menees dans la Cochrane Library et Medline afin d'y trouver les articles, publies entre 1966 et 2005, traitant de la prise en charge conservatrice de l'incontinence. Les exposes de synthese ont ete evalues. Valeurs La qualite des resultats a ete evaluee et les recommandations ont ete etablies au moyen des criteres decrits par le Groupe d'etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts Les resultats qui sous-tendent les options de prise en charge conservatrice de l'incontinence urinaire sont solides. Ces options peuvent etre recommandees a titre d'interventions primaires ne presentant que des desavantages minimaux ou meme inexistants pour les femmes. Recommandations 1.La mise en œuvre d'exercices de reeducation du plancher pelvien (Kegel) devrait etre recommandee pour les femmes qui presentent une incontinence a l'effort (I-A). 2.L'execution en bonne et due forme des exercices Kegel devrait etre confirmee par examen vaginal digital ou par retroaction biologique (I-A). 3.Un suivi devrait etre mis en œuvre pour les femmes qui ont recours a la reeducation du plancher pelvien, puisque les taux de guerison sont faibles et que d'autres traitements peuvent s'averer indiques (III-C). 4.Dans le cas du syndrome de la vessie hyperactive (VHA), les exercices Kegel peuvent etre offerts a titre de traitement d'appoint s'ajoutant a d'autres traitements, mais ils ne doivent pas constituer le seul traitement offert en vue de contrer les symptomes en cause (I-B). 5.Bien que l'electrostimulation fonctionnelle (ESF) n'ait pas ete etudiee a titre de modalite independante, elle peut etre utilisee a titre de traitement d'appoint accompagnant la reeducation du plancher pelvien, particulierement chez les patientes qui ont de la difficulte a identifier et a contracter les muscles pelviens (III-C). 6.L'ESF devrait etre offerte a titre d'option efficace pour la prise en charge de la VHA (I-A). 7.Le recours aux cones vaginaux peut etre recommande en tant que forme de reeducation du plancher pelvien pour les femmes qui presentent une incontinence a l'effort (I-A). 8.Les pessaires de continence devraient etre offerts aux femmes a titre de modalite de traitement efficace et n'entrainant que de faibles risques contre tant l'incontinence a l'effort que l'incontinence mixte (II-B). 9.La reeducation vesicale (exercices vesicaux) devrait etre recommandee pour les symptomes associes a la VHA, puisqu'elle ne s'accompagne d'aucun effet indesirable (III-C), et qu'elle s'avere aussi efficace que la pharmacotherapie (I-B). 10.Les protocoles de prise en charge comportementale qui font appel a des modifications du mode de vie, conjointement avec la mise en œuvre d'une reeducation vesicale et d'exercices des muscles pelviens, s'averent grandement efficaces et devraient etre utilises dans la prise en charge de l'incontinence urinaire (I-A).

Objective To outline the evidence for conservative management options for treating urinary incontinence. Options Conservative management options for treating urinary incontinence include behavioural changes, lifestyle modification, pelvic floor retraining, and use of mechanical devices. Outcomes To provide understanding of current available evidence concerning efficacy of conservative alternatives for managing urinary incontinence; to empower women to choose continence therapies that have benefit and that have minimal or no harm. Evidence The Cochrane Library and Medline (1966 to 2005) were searched to find articles related to conservative management of incontinence. Review articles were appraised. Values The quality of evidence is rated, and recommendations are made using the criteria described by the Canadian Task Force on Preventive Health Care. Benefits, Harms, Costs Evidence for the efficacy of conservative management options for urinary incontinence is strong. These options can be advocated as primary interventions with minimal or no harm to women. Recommendations 1.Pelvic floor retraining (Kegel) exercises should be recommended for women presenting with stress incontinence (I-A). 2.Proper performance of Kegel exercises should be confirmed by digital vaginal examination or biofeedback (I-A). 3.Follow-up should be arranged for women using pelvic floor retraining, since cure rates are low and other treatments may be indicated (III-C). 4.Kegel exercises may be offered as an adjunct to other treatments for overactive bladder (OAB) syndrome, but they should not be the only treatment offered for these symptoms (I-B). 5.Although functional electrical stimulation (FES) has not been studied as an independent modality, it may be used as an adjunct to pelvic floor retraining, especially in patients who have difficulty identifying and contracting the pelvic muscles (III-C). 6.FES should be offered as an effective option for the management of OAB (I-A). 7.Vaginal cones may be recommended as a form of pelvic floor retraining for women with stress incontinence (I-A). 8.Continence pessaries should be offered to women as an effective, low-risk treatment for both stress and mixed incontinence (II-B). 9.Bladder training (bladder drill) should be recommended for symptoms of OAB, since it has no adverse effects (III-C), and it is as effective as pharmacotherapy (I-B). 10.Behavioural management protocols using lifestyle changes in combination with bladder training and pelvic muscle exercises are highly effective and should be used to treat urinary incontinence (I-A).

Background and aims: Individuals with non-acute pain are challenged with variable pain responses following surgery as well as psychological challenges, particularly depression and catastrophizing. The purpose of this study was to compare pre- and postoperative psychosocial tests and the associated presence of sensitization on a cohort of women undergoing elective laparoscopic surgery for non-acute pain defined as pain sufficient for surgical investigation without persistent of chronic pain. Methods: The study was a secondary analysis of a previous report (Am J Obstet Gynecol 2014 Oct;211(4):360–8.). The study was a prospective cohort trial of 77 women; 61 with non-acute pain and 16 women for a tubal ligation. The women had the following tests: Pain Disability Index, Pain Catastrophizing Scale, CES-D (Center for Epidemiologic Studies Depression Scale) depression scale and the McGill Pain Scale (short form) as well as their average pain score and the presence of pain sensitization. All test scores were correlated together and comparisons were done using paired t-test. Results: There were reductions in pain and psychosocial test scores that were significantly correlated. Pre-operative sensitization indicated greater changes in psychosocial tests. Conclusions: There was a close association of tests of psychosocial status with average pain among women having surgery on visceral tissues. Incorporation of these tests in the pre- and postoperative evaluation of women having laparoscopic surgery appears to provide a means to a broader understanding of the woman’s pain experience.

Background Research on the health benefits of cannabis has been limited because use remains restricted or illegal in most countries. Medical cannabis has been legal in Canada since 2001 and recreational use became legal in October 2018. While there are data that support a biological mechanism by which cannabinoids can impact various other symptoms of MS, the evidence of effectiveness of cannabis as a treatment for bladder symptoms remains unsettled. We conducted an exploratory study to describe the current trends of cannabis product consumption among people with MS (PwMS) and their association with perceived benefits on MS symptoms. Methods A cross-sectional survey study of PwMS, recruited from the MS Clinic in Calgary, Alberta, Canada was undertaken. Logistic regression analyses were performed to assess the associations between cannabis consumption and improvement in bladder function symptoms. Results There were 775 respondents out of 2899 PwMS contacted by email. Among respondents, 734 reported cannabis use in the past 3 months. There were 275 (37.5%) respondents who reported cannabis use in the prior 3 months, and 73.8% of these reported at least weekly use of cannabis. Among all users, 78.1% reported a primary medical or therapeutic indication for consumption. The most common modes of cannabis consumption were oral-edible (69.0%) and smoked (57.1%), while 59.3% used more than one mode of consumption and 2.6% used five different modes. The most common reasons for cannabis use were for sleep (58.3%), pain (51.5%), relaxation (44.4%), muscle spasms (40.2%), anxiety (33.8%) and depression (22.9%). Among the 19 participants who reported bladder symptoms as a main reason for cannabis use, 89.5% reported “better” bladder symptoms when using cannabis. Cannabis consumption in the past 3 months was associated with a two-fold increased odds of reporting improvement in urinary frequency, urinary urgency, bladder leakage and wetness, pad use and bladder emptying. Conclusions Cannabis is commonly used in this survey study of personal cannabis use among PwMS. Patterns of use, dosing, frequency and mode of delivery are diverse among survey respondents. This pilot study provides some initial glimpses into real world therapeutic use of cannabinoids among PwMS for bladder symptoms.

Introduction Botulinum toxin has proven therapeutic effects in alleviating pain in several myofascial disorders, with an expanding potential in chronic pelvic pain. The objective of this systematic review is to evaluate the efficacy and safety of botulinum toxin injection as an off-label treatment for female chronic pelvic pain. Material and methods Using PRISMA guidelines, MEDLINE, EBM Reviews, PubMed, CINAHL, TRIP Database, EMBASE, Web of Science and gray literature were searched. Studies assessing the efficacy of botulinum toxin for chronic pelvic pain in adult females, with 10 or more women, published in English up to 13 January 2020, were included. All eligible studies were reviewed and data were extracted by two independent reviewers using a standardized form. Quality of evidence was graded using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Ottawa-Newcastle scale for observational studies. Results In all, 491 records were screened. Seventeen articles were included in the final review: 5 randomized controlled trials and 12 observational studies. The quality of evidence ranged from low to high. There was a large degree of heterogeneity in study designs, and thus a meta-analysis was not feasible. All observational studies concluded that botulinum toxin was an effective treatment for chronic pelvic pain, with the greatest change in visual analog scale from 8.69 at baseline to 3.07 at 24 months post-injection. However only one of the five randomized controlled trials found statistical significant differences favoring botulinum toxin in the reporting of the EQ-5D (botulinum 0.78 [0.69-1.00], control 0.69 [0.25-0.81], P = .03) and frequency of intercourse (botulinum 1 [1-1.75], placebo 1 [0-1], P = .025). The most common adverse effect was transient localized pain at injection site (6%-88%). No serious adverse events were reported. Conclusions Although observational studies were encouraging, there is insufficient high quality evidence to recommend botulinum toxin injection for chronic pelvic pain. However, it appears to be safe to use. Future studies of higher quality in its treatment efficacy are indicated.

Objective To review the use, care, and fitting of pessaries. Target population Women requiring the use of vaginal pessaries for pelvic organ prolapse and/or stress urinary incontinence. Use may also be indicated for women with certain pregnancy-related clinical scenarios, including incarcerated uterus. Options Pessaries are an option for women presenting with prolapse and/or stress urinary incontinence. In addition, certain types of pessaries can be considered for patients with cervical insufficiency or incarcerated uterus. Outcomes Most women with prolapse or stress urinary incontinence can be successfully fitted with a pessary and experience excellent symptom relief, high satisfaction rates, and minimal complications. Benefits, harms, and costs Women with pelvic organ prolapse and/or stress urinary incontinence may choose to use a pessary to manage their symptoms rather than surgery or while waiting for surgery. Major complications have been seen only when pessaries are neglected. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated. Evidence Medline was searched for relevant articles up to December 2018. This is an update of the SOGC technical update published in 2013, which was the first internationally published guidance on pessary use. Subsequently, an Australian guideline on the use of pessaries for the treatment of prolapse was published later in 2013. Validation methods The authors rated the quality of evidence and strength of recommendations using the approach of the Canadian Task Force on Preventive Health Care (Appendix A). Intended audience Gynaecologists, obstetricians, family physicians, physiotherapists, residents, and fellows. SUMMARY STATEMENTS 1Most women can be successfully fitted with a pessary to treat the symptoms of pelvic organ prolapse or stress urinary incontinence (II-2). 2Satisfaction rates for pessary use are very high (I). 3Some vaginal pessaries may prevent recurrence of incarcerated uterus (III). 4The role of pessaries specifically designed to prevent preterm labour is not yet elucidated (I). 5Complications associated with pessary use are usually minor, with vaginal discharge being the most common problem (II-3). 6Vaginal erosions can be treated with removal of the pessary and optional vaginal estrogen supplementation (II-2). RECOMMENDATION 1Pessaries should be considered in all women presenting with bothersome pelvic organ prolapse and/or stress urinary incontinence (I, A).

Objective To evaluate the acceptability, feasibility, and outcomes of pessary fitting in rural Nepali communities. Methods A 1-year prospective cohort study was conducted in the Ramechhap district of Nepal in January 2013–January 2014 among women attending a free gynecology health camp. All women with symptomatic pelvic organ prolapse (POP) were offered ring pessaries. Demographic information was collected and questionnaires on POP were completed. A urogynecologic examination was performed. At the 1-year follow-up, women were questioned on pessary use and underwent an examination. Logistic regression was used to identify associations. Results In total, 411 women attended the health camps, of whom 142 presented with symptomatic POP. Initial fitting was accomplished for 134 (94.4%) of the women. At the 1-year follow-up, 130 (97.0%) women in the cohort were evaluated, and 72 (55.4%) were still using the pessary. The primary reason for discontinuation was the pessary falling out (35/58, 60.3%). The most common complication was vaginal erosion (18/130, 13.8%), observed exclusively among postmenopausal women. Postmenopausal status was a predictor of continued use (odds ratio 3.12, 95% confidence interval 1.45–6.72; P=0.004). Conclusion Pessaries were found to be an acceptable and feasible option with minimal complications for treating POP in rural Nepal. This article is protected by copyright. All rights reserved.

Objective To conduct an economic evaluation of the use of trans-obturator tape (TOT) compared with tension-free vaginal tape (TVT) in the surgical treatment of stress urinary incontinence in women. Design Cost–utility and cost-effectiveness analyses from a public-payer perspective, conducted alongside a randomised clinical trial. Setting Health services provided in Alberta, Canada. Sample A total of 195 women participated in the randomised clinical trial, followed to 5 years postsurgery. Methods Comparisons were undertaken between study groups for cost and two health-outcome measures. Multiple imputation was used to estimate the 14% of missing data. Bootstrapping was used to account for sampling uncertainty. Sensitivity analyses were based on complete case analyses and the removal of a TVT patient with extreme health service cost. Main outcome measures The 15D instrument was used to calculate quality-adjusted life-years (QALYs) for the primary analysis. Absence of serious adverse events was also analysed. Costs were based on inpatient and outpatient hospital use data and practitioner fee-for-service claims data. Results The TOT group had a nonsignificant average saving of $2368 (95% CI −$7166 to $2548) and incremental gain of 0.04 QALYs (95% CI −0.06 to 0.14) compared with TVT. TOT was dominant in over 71% of bootstrap replications and cost-effective over a wide range of willingness-to-pay. Cost-effectiveness analysis using the absence of an serious adverse events provided similar results. Conclusion The results suggest that TOT is cost-effective compared with TVT in the treatment of stress urinary incontinence. Tweetable abstract The results of a 5-year cost-effectiveness analysis suggest that trans-obturator tape is cost-effective compared with tension-free vaginal tape in the treatment of stress urinary incontinence.

Data on the incidence of perioperative complications of surgical procedures for pelvic organ prolapse (POP) and their contributing factors are limited, sometimes conflicting, and often mixed with other urogynecologic surgeries. To estimate the incidence and contributing factors for perioperative complications of POP procedures. A cross-sectional study was carried out between November 2016 and June 2017. POP procedures of different approaches were included irrespective of the surgeon involved, type of surgery (primary or repeat), or concomitant hysterectomy or incontinence repair. Data on perioperative complications were recorded prospectively. A total of 366 women were included in the current analysis. The average age was 61.0 ± 13.4 years. The surgical procedures performed were vaginal (75.3%), abdominal (11.3%), or combined (13.4%). Approximately 18.2% of these procedures were repeat surgeries. A total of 38 (11.3%) women developed perioperative complications (3.6% severe and 7.7% minor). These included: 25 (7.4%) intraoperative complications (2.4% severe and 5.1% minor) and 17 (5.1%) postoperative complications (2.1% severe and 3.0% minor). In multivariate analysis, abdominal surgery and McCall culdoplasty were significant predictors of intraoperative complications (alone or when combined with other postoperative complications). On the other hand, concomitant hysterectomy and concomitant incontinence repair procedure were associated with higher postoperative complication rates while vaginal surgery had fewer postoperative complications. There was a low rate of perioperative complications. Abdominal surgery and McCall culdoplasty showed higher intraoperative complications. These data should help in preoperative counseling and target ways to further decrease complication rates.

To outline the evidence for conservative management options for treating urinary incontinence.Conservative management options for treating urinary incontinence include behavioural changes, lifestyle modification, pelvic floor retraining, and use of mechanical devices.To provide understanding of current available evidence concerning efficacy of conservative alternatives for managing urinary incontinence; to empower women to choose continence therapies that have benefit and that have minimal or no harm.The Cochrane Library and Medline (1966 to 2005) were searched to find articles related to conservative management of incontinence. Review articles were appraised.The quality of evidence is rated, and recommendations are made using the criteria described by the Canadian Task Force on Preventive Health Care.Evidence for the efficacy of conservative management options for urinary incontinence is strong. These options can be advocated as primary interventions with minimal or no harm to women.

Background Vaginal steaming has gained increased popularity as a method to achieve empowerment by providing vaginal tightening and to “freshen” the vagina. Case A 62-year-old woman sustained second-degree burns following vaginal steaming in an attempt to reduce vaginal prolapse. Conclusion Clinicians need to be aware of alternative treatments available to women so that counselling may mitigate any potential harm.

In a randomised trial comparing transobturator tape (TOT) to retropubic tension-free vaginal tape (TVT) for women with stress urinary incontinence (SUI), vaginal examination at 12 months showed that tapes were palpable for 80.0 % of the TOT group versus 26.7 % of the TVT group. We hypothesized that this difference would lead to more women in the TOT group experiencing vaginal mesh erosion or other serious adverse events compared to women in the TVT group 5 years after surgery. All participants were invited to join the follow-up study after being randomised to receive TOT or TVT for SUI. Consenting women had a vaginal examination, a pad test for urinary incontinence (UI) and completed Health-related Quality of Life Questionnaires (HRQOL). Women unable to attend the clinic completed questionnaires only. The primary composite outcome incorporated mesh exposure, urinary retention, repeat incontinence surgery and moderate to severe pelvic pain. Assuming 80 % follow-up, our study would have 67 % power to detect a difference in primary outcome (two-sided 5 % level of significance). Comparisons between groups used chi-square tests and t tests. One hundred and seventy-six (88.4 %) women participated in the 5-year follow-up (83 TOT, 93 TVT). The primary composite outcome occurred in 21.8 % of the TOT and 27.6 % of the TVT groups [difference =−5.8 %, 95 % confidence interval (CI) −18.9 % to 7.3 %, p value 0.39)] Vaginal examination found more women with palpable tapes in the TOT versus the TVT group (48.5 % versus 22.4 %, p value 0.001). There were no other significant differences between groups. Serious adverse events and tape effectiveness did not differ between groups at 5 years. Palpable tape remains a concern for women who receive TOT for treating SUI.

To document the success rates and complications of salpingectomy performed at the time of vaginal hysterectomy to possibly reduce ovarian cancer rates.Retrospective cohort study (Canadian Task Force Classification II-2).Community-based hospital with university affiliation in Calgary, Canada.All women undergoing hysterectomy for benign conditions were offered preferentially a vaginal approach with prophylactic salpingectomy.During the study period (October 2011 to January 2014), a total of 425 vaginal hysterectomies were performed. The overall success rate of salpingectomy was 88%. Pelvic adhesions significantly predicted the ability to perform salpingectomies (odds ratio, 6.3; 95% confidence interval, 2.8-14.3; p.001). Age also was predictive of outcomes (p = .007), with increasing age predicting decrease success. The overall postoperative complication rate was 15%, with 3.8% possibly attributable to salpingectomy (i.e., intrapelvic complications). No associated factors were found on regression analysis.Salpingectomy at the time of vaginal hysterectomy is a feasible procedure. Complication rates are low. Only pelvic adhesions are associated with failure to complete a salpingectomy.

Objective In 1981 McKinlay described “Seven Stages in the Career of a Medical Innovation”. We wished to examine whether the model fits a modern device life cycle, and to comment on device manufacturers׳ influence on the life cycle. We chose to study the complete life cycle of TVT Secur, a mesh kit for surgical treatment of stress urinary incontinence in women, from its marketing in 2006 to device discontinuation for commercial reasons in March 2013. Methods A PubMed review was undertaken to identify all published literature related to TVT Secur from 2006 to November 2014. Each publication was classified according to McKinlay׳s seven stages. Results Eighty-three relevant publications from 22 countries were identified: 4 promising reports, 1 professional adoption, 0 third-party endorsement, 34 standard procedure, 19 randomised controlled trials (RCTs) from 2010 and mainly describing comparisons with other TVT family members), 0 professional denunciation of RCT findings, and 4 erosion and discreditation. Conclusions McKinlay׳s seven stages model was useful to describe TVT Secur׳s truncated life cycle. TVT Secur, fully approved and licensed according to all jurisdictional requirements, generated many descriptive cohort studies but more rigorous RCT evidence appeared only half way through its life cycle. Device discontinuation meant that the stage of erosion and discreditation described by McKinlay occurred after TVT Secur was no longer available. We suggest that careful premarket evaluation of safety and effectiveness might decrease the need for commercial discontinuation of devices, and that post-marketing evaluation is a crucial mechanism to protect patients from harm.

Patient history is often insufficient to identify type of urinary incontinence (UI). Multichannel urodynamic testing (UDS) is often used to clarify the diagnosis. Dynamic cystoscopy (DC) is a novel approach for testing bladder function. The primary objective of this study was to investigate the diagnostic agreement of UDS and DC in evaluating women with mixed urinary incontinence (MUI). Women presenting with MUI were approached for enrollment if UDS and DC were planned for further investigation. Investigators were blinded to history and comparative test results. McNemar’s test and kappa coefficient were calculated to assess agreement between UDS and DC. Receiver operating characteristic (ROC) analysis was used to explore the best possible filling sensation cutoffs for DC that would best predict the filling sensation cutoffs from UDS. Sixty participants were included, of whom, four were excluded for protocol violation. For the primary outcome measure of agreement, UDS and DC were concordant in 44/56 of stress urinary incontinence (SUI) cases (79%) with a κ= 0.54 and in 43/56 of urinary urge incontinence (UUI) cases (77%) with a κ= 0.54, indicating moderate, nearly substantial agreement. ROC analysis identified the best prediction of DC first urge to void as 148 cm3, strong urge 215 cm3, and maximum capacity at 246 cm3. These parameters were used to compare UDS UUI to DC UUI and resulted in a κ = 0.61 (p = 0.37), indicating substantial agreement. When compared with UDS, DC shows moderate agreement for detection of SUI and substantial agreement for detection of UUI.

Objective To evaluate impact of body mass index (BMI) ≥30 on objective and subjective cure rates 12 months after midurethral sling surgery. Design Secondary analysis. Setting Three hospitals in Calgary, Canada, 2005–07. Population A total of 182 women enrolled in a randomised control trial of tension-free vaginal tape versus transobturator tape. Methods Women were classified as obese or nonobese from height and weight on day of surgery. Women underwent postoperative standardised pad tests, self-reporting of urinary incontinence, and quality of life scores. Categorical data compared with chi-square or Fisher's exact, continuous data compared with Mann–Whitney U test. Main outcome measures Primary outcome was objective cure, defined as

To compare anatomical and patient-reported outcomes at 12 months postoperatively for women who had anterior compartment pelvic organ prolapse (POP) surgery using a repair augmented with porcine small intestine submucosa mesh (Mesh Group) compared with those who had a native tissue repair (No Mesh Group).This was a randomized controlled trial with 12 months follow-up. The surgical procedure was identical in both groups except for the placement of intervening mesh. The primary outcome was anatomical "cure" (Ba of -1 or less on Pelvic Organ Prolapse Quantification [POP-Q]). Secondary outcomes included POP-Q stage, patient-reported outcomes, and patient satisfaction. The study was powered to detect a 40% difference at 80% power (α=0.05).Fifty-seven women were randomized (28 to Mesh Group, 29 to No Mesh Group). Forty-five (79%) underwent concomitant surgery. At the 12-month follow-up, 56% (15/27) in the Mesh Group and 61% (17/28) in the No Mesh Group were considered cured (relative risk 0.90, 95% confidence interval 0.52-1.54). There were no significant differences between groups in recurrent or persistent prolapse (7% in each group) nor in patient-reported outcomes at 12 months. Pelvic girdle pain occurred in 4 of 27 in the Mesh Group and 3 of 28 in the No Mesh Group.No significant differences were observed in anatomical or patient-reported outcomes outcome parameters at 12 months after correction of symptomatic anterior POP by mesh or no mesh repair. In our study, porcine small intestine submucosa mesh did not confer additional benefit over a native tissue repair.ClinicalTrials.gov, www.clinicaltrials.gov, NCT0095544. LEVEL OF EVEDIENCE: I.

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)

Early voiding dysfunction (EVD) with urinary retention (UR) is a complication of midurethral sling (MUS) surgery. Management is not standardized. Our objective was to characterize management approaches at our center, and report outcomes including resolution of UR, persistent voiding dysfunction, and recurrent stress urinary incontinence (SUI). All women requiring catheterization for ≥7 days after MUS surgery during the period March 2014 to 2016 were eligible for inclusion in this prospective study. The management plan for each patient was decided jointly by the surgeon and the patient. Questionnaires regarding urinary symptoms were administered at enrollment, and 3 and 6 months after surgery. The timing and type of any surgical intervention were recorded. During the 2-year period, 31 women experienced EVD for ≥7 days after MUS surgery. At 6 months, complete data were available for 30 women (97%). Two management approaches were identified: “early mobilization” to loosen the MUS intact (in 10 patients), and continued catheterization with delayed sling lysis as needed (in 21 patients). In eight of the ten women in the early mobilization group, UR resolved after one intervention. Two required a second mobilization. For all women in this group, UR resolved after one or two procedures. In 11 of the 21 women in the continued catheterization group UR resolved without intervention. The other ten women in the continued catheterization group opted for sling lysis ≤6 months after MUS surgery. None of the women in the mobilization group reported SUI at 6 months in contrast to 9 of 20 (45%) in the planned continued catheterization group (p = 0.029). Seven of the nine women experiencing recurrent SUI had undergone sling lysis. Patients experiencing EVD after MUS surgery can be informed that UR will resolve in 50% with continued catheterization. Mobilization should be an option for those not comfortable with prolonged catheterization. Early intervention by mobilization may be associated with a lower risk of recurrent SUI, compared to continued catheterization and delayed sling lysis.