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Pelvic organ prolapse is a very frequent affection especially in elderly women. Vaginal pessary is a common conservative treatment and recommended as first line therapy. Guidelines recommend to do a regular follow up every 6 to 12 months with a healthcare professional. We report the case of a patient with neglected vaginal pessary who had a vesicovaginal and a concomitant rectovaginal fistula.A 84-year-old woman was admitted for chronic pelvic pain and vaginal discharge. An entrapped cube pessary was removed and the diagnostic of a 3cm rectovaginal fistula with a vesicovaginal fistula was made. The patient had a two-stage surgery, vaginal way then open abdominal way, for closing the fistulas.Although vaginal pessary is a good conservative treatment for POP, it shall not be neglected or serious complications can be caused.

Resume Objectif Determiner l’interet ou non de la realisation de certains gestes prophylactiques en association a une procedure chirurgicale gynecologique. Conception Un comite de consensus de 19 experts a ete constitue. Une politique de declaration et de suivi des liens d’interets a ete appliquee et respectee durant tout le processus de realisation du referentiel. De meme, celui-ci n’a beneficie d’aucun financement provenant d’une entreprise commercialisant un produit de sante (medicament ou dispositif medical). Le comite de consensus devait respecter et suivre la methode GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour evaluer la qualite des donnees factuelles sur lesquelles etaient fondees les recommandations. Les inconvenients potentiels de faire des recommandations fortes en presence de donnees factuelles de mauvaise qualite ou insuffisantes ont ete soulignes. Peu de recommandations ont ete non graduees. Methodes Le comite a etudie 22 questions concernant 7 thematiques. Les gestes associes a une procedure chirurgicale gynecologique etudies etaient les suivants : 1) Salpingectomie, 2) Realisation d’une fimbriectomie, 3) Annexectomie, 4) Destruction d’endometriose superficielle, 5) Adhesiolyse, 6) Destruction endometriale, 7) Ablation du col uterin. Resultats Le travail de synthese des experts et l’application de la methode GRADE ont abouti a 34 recommandations. Parmi les recommandations formalisees, six ont un niveau de preuve eleve (GRADE 1+/−) et 28 un niveau de preuve faible (GRADE 2+/−). Pour deux questions, la methode GRADE ne pouvait pas s’appliquer en raison d’une absence de litterature medicale, ne permettant pas d’aboutir a une recommandation. Conclusion Un accord important existait parmi les experts sur des recommandations fortes dans le but de d’ameliorer les pratiques pour la realisation ou non de certains gestes prophylactiques en association a une chirurgie gynecologique.

OBJECTIVE Immediate postoperative urinary retention (UR) and voiding dysfunction (VD) are some factors limiting outpatient procedure for mid-urethral sling (MUS) surgery in women presenting with stress urinary incontinence. The objective of the current review was to report the main predictive factors associated with immediate postoperative UR/VD following MUS surgery in women. METHODS A systematic review was performed using Medline database, according to PRISMA methodology, using following keywords midurethral sling; tension-free vaginal tape; TVT; transobturator tape; TOT; predicting factor; voiding dysfunction; urinary retention; postvoid residual; postoperative residue of urine. RESULTS Thirteen studies were included. Main clinical predictive factors associated with immediate postoperative urinary retention (UR) and voiding dysfunction (VD) were: previous pelvic surgery (hysterectomy, incontinence or pelvic organ prolapse surgery) [OR: from 3.7 ((CI95%: 1.14-12.33); P=0.029)] to 8.93 [(CI95%:1.17-61.1); P=0.035)], previous UR [OR: 415 (CI95%: 20-8619); P

The aim was to evaluate the reoperation rate and outcomes in women who underwent transvaginal non-absorbable monofilament polypropylene mesh placement for the treatment of cystocele. The retrospective cohort study included 63 patients who underwent transvaginal surgery using a synthetic polypropylene mesh (Gynemesh™) for cystocele. Patients were evaluated using a clinical examination (POP-Q) and validated questionnaires (PGI-I, PFDI-20, PFIQ-7) at 18 years of follow-up (median 18 years [IQR 16–19]). Cumulative death rate was 13 out of 63 (20%) and rate of total loss to follow-up was 21 out of 50 (42%). Finally, among the 63 women who underwent surgery, 29 completed maximum follow-up and 21 underwent a clinical examination. The cumulative reoperation rate was 35% (22 out of 63). Three patients were reoperated on because of recurrence of pelvic organ prolapse. Among the 63 patients initially operated, vaginal mesh exposure occurred in 16 (25%) during follow-up and 11 women (17%) needed a reintervention for vaginal mesh exposure. One patient was reoperated on for bladder mesh exposure. Among the 29 women who completed follow-up, the overall postoperative improvement rate was 93% after 18 years (PGI-I: 1–3). Mean overall satisfaction rate was 80 out of 100. Functional success rate was 76% (22 out of 29) and anatomical success rate was 62% (13 out of 21). The median score of the POP-DI-6 was 4.1 (IQR: 0–11) and the median score of the PFDI-20 was 30.7 (IQR: 13–60) in the 29 women who completed maximum follow-up. At very long-term follow-up, the recurrence rate of cystocele following polypropylene mesh placement by the vaginal route remained low and the satisfaction rate was high. However, we found high cumulative reoperation and mesh exposure rates.

(1) Background: Pelvic organ prolapse (POP) can be managed using a vaginal pessary. However, the decision-making process whereby health professionals choose the right pessary is unclear. The objective of this study was to focus on the experience of experts in pessary use and to propose an algorithm. (2) Methods: A prospective study, based on face-to-face semi-directive interviews and group discussions, was conducted on a multidisciplinary panel of professional experts specialized in pessary prescriptions. A consensual algorithm was established, and its accuracy was assessed by expert and non-expert panels. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) were used. (3) Results: 17 semi-directive interviews were conducted. The parameters involved in the decision-making process regarding the choice of vaginal pessaries were: desire for self-management (65%), associated urinary stress incontinence (47%), POP type (41%), and POP stage (29%). The algorithm was developed step by step (4 iterations) using the Delphi technique. Most of the expert panel (76%) rated the relevance of the algorithm as 7 or more out of 10 on a visual analog scale according to their own experience (reference activity). Finally, most (81%) of the non-expert panel (n = 230) rated the usefulness of this algorithm as 7 or more out of 10 on a visual analog scale. (4) Conclusions: This study provides an expert panel-based algorithm that may help in the prescription of pessaries for POP.

Objective: To evaluate the rates of serious complications and reoperation for recurrence following sacrospinous ligament fixation (SSLF) for apical pelvic organ prolapse. Methods: This was a national registry ancillary cohort comparative study. The VIGI-MESH registry includes data from 24 French health centers prospectively collected between May 2017 and September 2021. Time to occurrence of a serious complication or reoperation for genital prolapse recurrence was explored using the Kaplan–Meier curve and Log-rank test. The inverse probability of treatment weighting, based on propensity scores, was used to adjust for between-group differences. Results: A total of 1359 women were included and four surgical groups were analyzed: Anterior SSLF with mesh (n = 566), Anterior SSLF with native tissue (n = 331), Posterior SSLF with mesh (n = 57), and Posterior SSLF with native tissue (n = 405). Clavien–Dindo Grade III complications or higher were reported in 34 (2.5%) cases, with no statistically significant differences between the groups. Pelvic organ prolapse recurrence requiring re-operation was reported in 44 (3.2%) women, this was higher following posterior compared with anterior SSLF (p = 0.0034). Conclusions: According to this large database ancillary study, sacrospinous ligament fixation is an effective and safe surgical treatment for apical prolapse. The different surgical approaches (anterior/posterior and with/without mesh) have comparable safety profiles. However, the anterior approach and the use of mesh were associated with a lower risk of reoperation for recurrence compared with the posterior approach and the use of native tissue, respectively.

BACKGROUND Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE. METHODS The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid. RESULTS The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication. CONCLUSION These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care. SIGNIFICANCE Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.

Resume Introduction Le diastasis des muscles droits de l’abdomen est frequent au cours de la grossesse et du post-partum. Objectif Determiner la prevalence de cette pathologie, les methodes de diagnostic, l’association avec les troubles pelvi-perineaux et les therapeutiques pouvant etre proposees. Methodes Revue de la litterature sur Pubmed, Medline, Embase et Cochrane en utilisant les mots et MeSH suivants : diastasis, diastasis and pregnancy, diastasis of the rectus abdominis muscle, increase of the inter-recti distance. Resultats Parmi les 124 articles que nous avons trouves, 61 ont ete retenus. L’echographie abdominale semble etre l’examen de choix tant sur le plan de la faisabilite que de la reproductibilite pour le diagnostic de cette pathologie (coefficients de correlation intra-classe (ICC) eleves 0,81 a 0,94). Les facteurs de risque mis en evidence sont variables selon les etudes : port de charge lourde (OR = 2,18 (IC 95 % 1,05 a 4,52) p = 0,04), prise de poids. Les resultats des etudes sont discordants concernant l’association entre le diastasis et les douleurs lombaires (RR = 1,39 (IC 95 % 0,91–2,14), p = 0,17), l’incontinence urinaire (RR = 0,86 (IC95 % 0,55–1,33) p > 0,65) et le prolapsus (OR = 2,25 (IC 95 % 1,51–3,37) p Conclusion Les connaissances sur les facteurs de risque, les consequences des diastasis et leur prise en charge sont encore limitees a ce jour. Il est donc necessaire d’etablir des etudes prospectives sur de plus grands effectifs afin d’ameliorer les connaissances sur les diastasis des muscles droits.

International audience; Despite pelvic organ prolapse being a universal problem experienced in nearly 50% of parous women, the surgical management of vaginal prolapse remains an enigma to many, with wide variation in the rates and types of intervention performed. As part of the 6th International Consultation on Incontinence (ICI) our committee, charged with producing an evidence-based report on the surgical management of prolapse, produced a pathway for the surgical management of prolapse. The 2017 ICI surgical management of prolapse evidence-based pathway will be presented and summarized. Weaknesses of the data and pathway will be discussed and avenues for future research proposed.

STUDY QUESTION Is the Sexual Activity Questionnaire (SAQ) a valid tool for patients treated for symptomatic endometriosis? SUMMARY ANSWER For women having surgical treatment for endometriosis, we determined that the SAQ is a valid and responsive tool. WHAT IS KNOWN ALREADY Endometriosis adversely affects sexual quality of life. Suitable validated sexual quality of life instruments for endometriosis are lacking both in clinical practice and for research. STUDY, DESIGN, SIZE, DURATION A total of 367 women with proven endometriosis undergoing medical or surgical treatment were included in an observational study conducted between 1 January 2012 and 31 December 2014 in two French tertiary care centers. Both hospitals are reference centers for endometriosis treatment. Of these 367 women, 267 were sexually active and constituted the baseline population. PARTICPANTS/MATERIALS, SETTINGS, METHODS Women >18 years old with histological or radiological proven endometriosis, consulting for painful symptoms of at least 3 months duration, infertility, or other symptoms (bleeding, cysts) were invited to complete self-administered questionnaires before (T0) and 12 months after treatment (T1). Tests of data quality included descriptive statistics of the data, missing data levels, floor and ceiling effects, structural validity and internal consistency.The construct validity was obtained by testing presupposed relationships between previously established SAQ scores and prespecified characteristics of the patients by comparing different subgroups of patients at T0. Sensitivity to change was subsequently calculated by comparing the SAQ score between T1 and T0 overall and for different subgroups of treatment. Effect sizes (to T1) were calculated according to Cohen's method. The minimally important difference was estimated by a step-wise triangulation approach (including anchor-based method). MAIN RESULTS AND THE ROLE OF CHANCE In total, 267 sexually active patients (204 surgical and 63 medical treatment) completed the SAQ at T0 and 136 (50.9%) at T1. The SAQ score ranged from 2.0 to 28.0 (mean ± SD: 16.8 ± 5.7).The SAQ score was one-dimensional according to the scree plot with good internal consistency (Cronbach alpha = 0.78, 95% CI 0.74-0.81) and had good discriminative ability according to pain descriptors and quality of life in endometriosis. The SAQ was responsive in patients treated by surgery but the effect size was low (0.3, 95% CI (0.0-0.6), P = 0.01). The minimally important difference was determined at 2.2. LIMITATIONS, REASONS FOR CAUTION The effect size for medical treatment was non-significant. Other effect sizes were low but statistically significant. This could be explained by lower libido due to progestin intake, which was used for both surgically and medically treated patients. WIDER IMPLICATIONS OF THE FINDINGS The SAQ is easy to use, valid and effective in assessing sexual quality of life in patients with endometriosis. This patient-reported score could be used as a primary outcome for future clinical studies. The minimally important difference estimation will be useful for future research. We recommend using 2.2 for the minimally important difference of the SAQ. STUDY FUNDING/COMPETING INTEREST(S) This work was funded by the 'Direction a la Recherche Clinique et a l'Innovation' of Versailles, France and the 'Institut de Recherche en Sante de la Femme' (IRSF). The authors have no conflicts of interest to declare.

Objective To provide guidelines from the French College of Obstetricians and Gynecologists (CNGOF), based on the best evidence available, concerning subtotal or total hysterectomy, for benign disease. Methods The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade, which depends on the quality of evidence (QE) (clinical practice guidelines). Results Conservation of the uterine cervix is associated with an increased risk of cervical cancer (0.05 to 0.27%) and an increased risk of reoperation for cervical bleeding (QE: high). Uterine cervix removal is associated with a moderate (about 11 min) increase in operative time when hysterectomy is performed by the open abdominal route (laparotomy), but is not associated with longer operative time when the hysterectomy is performed by laparoscopy (QE: moderate). Removal of the uterine cervix is not associated with increased prevalence of short-term follow-up complications (blood transfusion, ureteral or bladder injury) (QE: low) or of long-term follow-up complications (pelvic organ prolapse, sexual disorders, urinary incontinence (QE: moderate). Conclusion Removal of the uterine cervix is recommended for hysterectomy in women presenting with benign uterine disease (Recommendation: STRONG [GRADE 1-]; the level of evidence was considered to be sufficient and the risk-benefit balance was considered to be favorable).

Invasive therapies (surgery or radiological embolization) are used to control severe post-partum hemorrhage. The intra-uterine tamponade balloon is a potential alternative, well documented after vaginal delivery. However, available data on its use after cesarean delivery remain scarce. This study assessed the efficacy of the intra-uterine tamponade balloon during post-partum hemorrhage in a cesarean delivery setting. Using a retrospective impact design, post-partum hemorrhage-related outcomes before (&ldquo, pre-balloon&rdquo, period) versus after implementation of intra-uterine tamponade balloon (&ldquo, post-balloon&rdquo, period) were compared. All women with post-partum hemorrhage requiring potent uterotonic treatment with prostaglandins after cesarean delivery over a 9-year period were eligible. The primary outcome was the rate of invasive procedure (conservative surgery, radiological embolization and/or hysterectomy). p &lt, 0.05 was considered statistically significant. A total of 279 patients were included (140 vs. 139). Most baseline characteristics were comparable between the two studied periods. The success rate of the intra-uterine tamponade balloon was 82%, and no related complications occurred. Rates of invasive procedures and transfusion were significantly reduced (28.6% vs. 11.5%, p &lt, 0.001 and 44.3% vs. 28.1%, p = 0.006 respectively) during the &ldquo, period, and length of hospital stay was shorter (p &lt, 0.001). Implementation of intra-uterine tamponade balloon during post-partum hemorrhage after cesarean delivery appears to be safe and effective, with a decrease in both invasive procedures and transfusion rates.

Journal of Gynecology Obstetrics and Human Reproduction - Vol. 49 - N° 8 - Article : 101841

Resume Introduction Cet article a pour objectif de faire la synthese des donnees disponibles dans la litterature sur les troubles fonctionnels du bas appareil urinaire (lower urinairy tract symptoms[LUTS]) apres mutilation sexuelle feminine (MSF). Materiels et methodes Notre revue de la litterature a permis d’identifier 177 publications, dont 14 ont ete incluses. Resultats En ce qui concerne les complications a court terme, la prevalence de la retention aigue d’urine (RAU) apres MSF est estimee entre 3 % et 12 %. En ce qui concerne les complications a long terme, les donnees sont discordantes concernant les infections urinaires a repetition (IUR) apres MSF avec une prevalence estimee entre 9 % et 39 %. La prevalence des LUTS est significativement augmentee chez les femmes ayant subi une MSF. Il y a, par exemple 5,17 IC 95 % (2,34–12,97) fois plus d’incontinence urinaire mixte chez les femmes ayant subi une MSF. La prevalence est d’autant plus elevee que la mutilation est importante. L’evolution des LUTS apres reconstruction clitoridienne n’a pas ete evaluee. Conclusion Des etudes supplementaires sont necessaires pour mieux caracteriser et evaluer la prevalence des LUTS apres MSF ainsi que l’interet et l’efficacite des differentes therapeutiques.

Aims Our purpose was to explore the involvement of cognition in voluntary and involuntary pelvic floor muscle (PFM) contraction in stress urinary incontinent women. Methods PFM contraction monitored by surface electromyography (EMG) was measured without a mental distraction task (DT), and with a DT called "paced auditory serial additional test" (PASAT). Forty stress incontinent women performed voluntary contractions of the external anal sphincter (EAS), and reflex EAS contractions induced by means of coughing were studied using the external intercostal muscle (EIC) EMG pattern. Results A DT altered PFM pre-activation when coughing: the reaction time between EIC muscle contraction and EAS contraction (called RT3) was respectively -54.94 ms (IQR -87.12; 3.12) without the PASAT and -3.99 ms (IQR: -47.92; 18.69) with a DT (P = 0.02, Wilcoxon's test). Concerning voluntary contraction, women activated their PFM sooner without than with a DT. Conclusion The PASAT altered voluntary and reflex contractions of the PFM in stress urinary incontinent women. Our study suggests that cognition plays a role in urinary pathophysiology. Future studies should investigate rehabilitation programs that consider the role of cognition in stress urinary incontinent women.

Objectives The main objective was to assess the reliability of the patient's measurement of diastasis. The secondary aims were the estimation postpartum diastasis prevalence, of diastasis-associated pelvic floor symptoms and quality of life immediately after childbirth and at 3−6 months postpartum. Study design Using a prospective observational design, women who gave birth in a French university hospital were eligible. After a learning phase, both clinician and patient conducted a clinical evaluation of diastasis. Then, patients were asked to complete the HerQLes, the FPFQ and a general questionnaire. Three to 6 months later, patients completed the same questionnaires online and performed a clinical evaluation of diastasis at home, as learned previously. Results Of 253 patients included in the study, 139 (54.9 %) completed the questionnaires at 3–6 months of follow-up. There was good correlation between clinician and patient evaluations of diastasis (kappa coefficient 0.76 [95 % CI, 0.5−0.7]). Immediately after childbirth, 210 (83 %) of the women presented diastasis including 116/210 (55 %) cases of severe diastasis and 51 (42 %) of those had persistent diastasis at 3−6 months of follow-up. Cesarean section (p = 0.05) and multiparity (p = 0.04) were factors of persistent diastasis. Severe diastasis had a significant impact on quality of life (HerQLes score) at birth (p = 0.001) and at 3−6 months (p = 0.01), but no effect on pelvic floor symptoms according the FPFQ. The occurrence and severity of diastasis did not significantly impact lumbar or pubic symphysis pain. Furthermore, the aesthetic discomfort felt by patients was significantly increased by the presence of diastasis on a numerical scale at 3−6 months (p = 0.03). Conclusion Good agreement between clinician and patient evaluations of postpartum diastasis indicated that the evaluation method is reliable. Persistent diastasis was associated with impaired quality of life.

Background: Cesarean section is one of the most common surgical procedures in young women. Cesarean scar defects may occur postoperatively and may cause symptoms such as chronic pain, postmenstrual bleeding as well as secondary infertility. Case presentation: We report the case of a 35-year-old woman who was referred to our center for the management of a large cesarean scar defect. She had history of two cesarean sections and presented with abnormal uterine bleeding, chronic pain and dyspareunia. Hysteroscopic examination showed the presence of a little isthmocele on the anterior uterine wall. Hysteroscopic resection with electrocoagulation was performed. The patient remained symptomatic and, unfortunately, five years later, magnetic resonance imaging (MRI) revealed a large anterior isthmocele (50x80 mm). A complete repair of the large defect was achieved by laparotomy.Postoperative MRI as well as hysteroscopic examination showed no signs of residual isthmocele. Conclusion: There are three main surgical options for isthmocele repair: vaginal approach, hysteroscopic resection or laparoscopic resection and repair of the uterine wall. While there is no clear consensus about general management of isthmocele, there are very few cases the medical literature of large isthmoceles, such as the one we describe. This case is interesting since no case of worsening of isthmocele following hysteroscopic treatment has been described so far.

International audience; OBJECTIVE: The aim of this article is to summarize the relevant findings that inform the 2017 International Consultation on Incontinence pathway for surgical treatment of pelvic organ prolapse (POP). METHODS: We conducted an evidence-based review of the English-language peer-reviewed literature relating to POP surgery published prior to December 2016. Level 1 evidence (randomized controlled trials [RCTs] or systematic reviews of RCTs) was preferred; however, level 2 (poor-quality RCT, prospective cohort studies) or 3 evidence (case series or retrospective studies) has been included if level 1 data were lacking. The committee evaluated the literature and made recommendations based on the Oxford grading system summarized as follows: grade A recommendation usually depends on consistent level 1 evidence; grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs; grade C recommendation usually depends on level 3 studies or "majority evidence" from level 2/3 studies or Delphi-processed expert opinion; grade D, "no recommendation possible," would be used where the evidence is inadequate or conflicting. RESULTS: The recommendations from each chapter of the review are presented and serve to inform an evidence-based pathway for the surgical treatment of prolapse. A Web-based interactive application of the pathway is presented. CONCLUSIONS: The 2017 International Consultation on Incontinence pathway on surgery for POP is designed as an adjunct to transparent consultation and consent relating to POP surgery. The final decision regarding surgical intervention can be made only after a shared decision-making process between the patient and the clinician that will evaluate a variety of individual factors that cannot be assessed in the pathway.

Objective: To report long term pregnancy rate in polycystic ovary syndrome (PCOS) treated by ovarian drilling. To evaluate predictive factors of pregnancy and possibility of a second drilling. Design: Retrospective, observational, multicenter study. Setting: Gynecologic departments of two teaching’s hospitals. Patients: All infertile women with PCOS who were treated by ovarian drilling from 2004 to 2013. The Rotterdam criteria were applied to define PCOS. Intervention(s): Surgical ovarian drilling by laparoscopy and trans vaginal hydro laparoscopy. Main Outcome Measure(s): The primary endpoint was pregnancy rate after ovarian drilling. The secondary endpoints were the predictive factors of pregnancy and the possibility of a second ovarian drilling. Results: 289 women were included in the study. The mean follow-up period was 28.4 months (25.3–31.5). A pregnancy was obtained in at least 137 (47.4%) women after a drilling, and 71 (51.8%) of these pregnancies were spontaneous, 48 (16.6%) women achieved at least two pregnancies after drilling, and 27 (56.3%) of these were spontaneous. The predictive factors for effectiveness were a normal body mass index (BMI), an infertility period of less than three years, an AFC of less than 50, and an age of less than 35. Second drillings were performed on 33 women. Among them, 19 (57.6%) achieved at least one pregnancy, and 10 (52.6%) of these were spontaneous. It appeared that a second drilling was effective either when the first drilling had been successful (pregnancy achieved after drilling) or when it had failed in cases of high AFC (greater than 55). Conclusion: Ovarian drilling permitted to obtain spontaneous pregnancy for women with PCOS. This surgery could have durably effect permitted to obtain more than one pregnancy. Keywords: Fertility, Polycystic ovary syndrome (PCOS), Ovarian drilling, Transvaginal hydrolaparoscopy, Anti-müllerian hormone

The diastasis of the rectus abdominis muscles is common during pregnancy and post-partum.To determine the prevalence of this pathology, methods of diagnosis, association with pelvic-perineal disorders and therapies that may be proposed.Review of Pubmed, Medline, Embase and Cochrane literature using the following words and MeSH: diastasis, diastasis and pregnancy, diastasis of the rectus abdominis muscle, increase of the inter-recti distance.Among the 124 articles found, 61 were selected. Ultrasound seems to be the exam of choice both in terms of feasibility and reproducibility for the diagnosis of this pathology (intra-class correlation coefficients (ICC) high 0.81 to 0.94). The risk factors identified vary from one study to another: heavy load bearing (OR=2.18 (95 % CI 1.05 to 4.52) P=0.04), weight gain. Studies are discordant regarding the association between diastasis and low back pain (RR=1.39 (95 % CI 0.91-2.14), P=0.17), urinary incontinence (RR=0.86 (95 % CI 0.55-1.33) P0.65) and prolapse (OR=2.25 (95 % CI 1.51-3.37) P0.001), but the diastasis seems to play a role in the alteration of the quality of life for these patients.Knowledge about risk factors, consequences of diastasis and management is still limited today. It is therefore necessary to establish prospective studies on larger numbers in order to improve knowledge on the diastasis of the rectus abdominis muscles.

Existen numerosas tecnicas de rehabilitacion perineal, empleadas con mucha frecuencia de forma conjunta. Durante el embarazo, se puede prescribir rehabilitacion perineal a las mujeres con incontinencia urinaria. En el posparto, se recomienda rehabilitacion perineal en la incontinencia urinaria o anal persistente a los 3 meses del parto (al menos tres sesiones dirigidas por un terapeuta), que debe incluir ejercicios de contraccion voluntaria de los musculos del piso pelvico. La rehabilitacion del posparto mejora la incontinencia urinaria y anal a corto plazo (1 ano), pero no a largo plazo (entre 6-12 anos). Para la incontinencia urinaria del posparto, se deben rehabilitar de seis a siete mujeres con incontinencia para que una de ellas sea continente al ano. La prevalencia de la incontinencia anal al ano del posparto es del 7% en las pacientes que han recibido rehabilitacion a los 3 meses del posparto frente al 13% en el grupo control. En las mujeres, con excepcion del embarazo y del posparto, la rehabilitacion perineal ha demostrado eficacia a corto plazo en el caso del tratamiento de la incontinencia urinaria de esfuerzo, la vejiga hiperactiva, los prolapsos genitales de estadio 1 o 2 (eficacia sobre la anatomia y los sintomas), los trastornos anorrectales (incontinencia anal, disquecia) y los trastornos sexuales (incontinencia urinaria coital, orgasmo, libido). No se ha demostrado beneficio alguno a largo plazo de esta rehabilitacion.

The sonographic features of endometriomas and their natural history during pregnancy remain poorly known. The objective of our study was to report our experience concerning the diagnosis, spontaneous progression and management of endometriomas during pregnancy.A retrospective observational study in 46 patients (53 cysts) presenting with an ovarian endometrioma diagnosed during ultrasound examination at the first trimester of pregnancy. Sonographic findings (according to the criteria of the International Ovarian Tumor Analysis (IOTA) group and how they changed for each cyst during pregnancy and postpartum were reviewed, together with cyst management. The median follow-up was 4 years [IQR: 3-6]. Median age at diagnosis was 31 years [IQR: 27-35].Among the 53 cysts identified as "endometriomas" on the first-trimester ultrasound examination, 49 (92%) were described like "cyst fluid with ground-glass echogenicity". Fifty-two cysts (98%) had a maximum diameter100mm, only one cyst (2%) presented papillary projection and 5 cysts (9%) were multiloculated. During the second-trimester ultrasound monitoring of these cysts, of the 33 cysts that we monitored, 8 (24%) increased in size, 11 (34%) decreased in size, 5 (15%) disappeared and 9 (27%) did not change. During the third-trimester ultrasound monitoring of these cysts, of the 13 cysts that we monitored, 5 (39%) increased in size, 5 (39%) decreased in size, 2 (15%) disappeared and 1 (7%) did not change. All children (48 newborns) were born alive at a median gestational age of 39 weeks [IQR=39-40]. Only 10 cysts (19%) required surgical treatment. In all cases, surgery consisted of cystectomy. Two cysts were operated on during pregnancy (between 14 and 17 weeks of gestation) because of symptoms of adnexal torsion, 3 during cesarean section, and 5 postpartum. Four of the 10 (40%) cysts operated on were histopathologically "endometriomas", and one of them was decidualized. Four cysts were mucinous cystadenomas, one was a serous cystadenoma and one cyst was a dermoid cyst.This study underscores the difficulty of diagnosing endometriomas during pregnancy and the absolute necessity of surgical removal when ultrasonographic findings are doubtful.

Objective Precise data are lacking concerning laparoscopic sacropexy in the elderly population. The purpose of this study was to compare the outcomes and complications associated with laparoscopic sacropexy (colpopexy or hysteropexy) in women aged under 70 and 70 or over. Study design Retrospective review of data on patients who underwent laparoscopic sacropexy in two tertiary centers. Peri- and postoperative complications were recorded and described using the IUGA classification. Surgery was considered successful if the patient was symptomatically satisfied or very satisfied and if the POP-Q (Pelvic Organ Prolapse-Quantification) stage score at the follow-up visit was below stage 2 for all compartments. Results Among the 191 women studied, 47 (24.6%) were aged 70 or more. According to the ICS/IUGA classification of POP complications, perioperative and postoperative complication rates were similar in the older versus younger groups (bladder injuries (0 vs. 1.39%, p = 1) (4A T1 S2), rectal injuries (0% vs. 0.69%, p = 1) (5BT1S5), vaginal injuries (2.13% vs. 0%, p = 0.246) (2A T1 S1)). No laparotomy conversion was required in either group. At two months of follow-up, the success rate was 97.9% and 95.1% in the older and younger groups, respectively (p = 0.68). At 24 months of follow-up, the overall reoperation rate was 12.8% for the older group versus 11.8% in the younger group (p = 0.80). Conclusions Our findings suggest that laparoscopic sacropexy is a valid option in elderly women presenting with genital prolapse.

Objective To make evidence-based recommendations for the postpartum management of women and their newborns, regardless of the mode of delivery. Material and methods Systematic review of articles from the PubMed database and the Cochrane Library and of recommendations from the French and foreign societies or colleges of obstetricians. Results Because breast-feeding is associated with reductions in neonatal, infantile, and childhood morbidity (lower frequency of cardiovascular, infectious, and atopic diseases and infantile obesity) (LE2) and improved cognitive development in children (LE2), exclusive and extended breastfeeding is recommended (grade B) for at least 4–6 months (professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (professional consensus). Because of potentially serious adverse effects, bromocriptine is contraindicated in inhibiting lactation (professional consensus). For women aware of the risks of pharmacological treatments to inhibit lactation but choose to take them, lisuride and cabergoline are the preferred drugs (professional consensus). Regardless of the mode of delivery, only women with bleeding or symptoms of anemia should be tested for it (professional consensus). Immediate postoperative monitoring after cesarean delivery should be performed in the postanesthesia care unit (PACU). An analgesic multimodal protocol for analgesia, preferring oral administration, should be developed by the medical team and be available for all staff (professional consensus) (grade B). Thromboprophylaxis with compression stockings should begin the morning of all cesarean deliveries and maintained for at least 7 postoperative days (professional consensus) with or without the addition of LMWH, depending on the presence and severity (major or minor) of additional risk factors. It is recommended that women be informed of the dangers of closely spaced pregnancies (LE3), that effective contraception begin no later than 21 days post partum for women who do not want such a pregnancy (grade B), and that it be prescribed at the maternity ward (professional consensus). In view of the postpartum risk of venous thromboembolism, use of combination hormonal contraception is not recommended before six weeks post partum (grade B). Pelvic floor rehabilitation in asymptomatic women to prevent urinary or anal incontinence in the medium or long term is not recommended (professional consensus). Rehabilitation using pelvic floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months post partum (grade A), regardless of the type of incontinence. Postpartum pelvic floor rehabilitation is recommended to treat anal incontinence (grade C), but not to treat or prevent prolapse (grade C) or dyspareunia (grade C). The months following the birth are a period of transition and of psychological changes for all parents (LE2) and are still more difficult for those with psychosocial risk factors (LE2). Situations of evident psychological difficulties can have a significant effect on the child's psychological and emotional development (LE3). Among these difficulties, postpartum depression is most common, but the risk of all mental disorders is generally higher in the perinatal period (LE3). Conclusion The postpartum period presents clinicians with a unique and privileged opportunity to address the physical, psychological, social, and somatic health of women and babies.

International audience; Introduction and hypothesis: Pelvic organ prolapse (POP) surgery using a mesh has a complication rate of 26%, and an estimated 10% of those operated on do not consider it brings improvement. The objective of this study was to identify preoperative predictors of improvement after POP repair with mesh to develop a predictive score. Methods: This is a secondary analysis of the randomized multicenter trial PROSPERE, which compared morbidity after prolapse repair with mesh according to the vaginal or laparoscopic approach. Improved women [PGI-I score at 1-year follow-up = 1 (much better) or 2 (better)] were compared with unimproved women. Two hundred fifty-five women were included to derive the prediction score based on multiple logistic regression. An internal validation by bootstrapping estimated the unbiased performance of the model. Results: Criteria independently related to improvement were: (1) cystocele stage > II [OR: 2.93 95% CI (1.22–7.04), p = 0.015]; (2) preoperative expectation related to bulge symptom improvement [OR: 2.57 95% CI (1.07–6.04), p = 0.031] and (3) absence of chronic pelvic pain [OR: 4.55 95% CI (1.77–11.46), p = 0.001]. A score (scored from 0 to 11) was constructed from the aOR of the predictive model: the ROC-AUC of the score was 0.75, and a score ≥ 9 predicted a 97% chance of improvement (95% CI 92–99), with a specificity of 85% (95% CI 68–94). The ROC-AUC corrected for optimism by the bootstrap procedure was 0.70. Conclusions: This score could be used by surgeons in preoperative counseling of women.

Postpartum pelvic floor disorders. Postpartum pelvic floor disorders are frequent but most of the time, decrease spontaneously. Even if 40% of pregnant women suffer from urinary incontinence, 85% of them are cured 3 months after delivery. In case of persistent urinary incontinence, postpartum rehabilitation improves short-term urinary incontinence. Six weeks after delivery 4% to 39% women suffer from anal incontinence. Most of the time anal symptoms decrease spontaneously. Postpartum rehabilitation seems to improve short-term anal incontinence. 15 to 20% of pregnant women have a genital prolapse stage 2 during the third trimester and 20 to 50% in the immediate postpartum. Even if most of the women (90%) have genital prolapse (stage 1 for most of them) one year after delivery, only 10% are bothered. Expectative management with a clinical evaluation 12 months after delivery is sufficient. In case of persistent symptoms, pelvic floor rehabilitation can be proposed.Troubles pelvi-périnéaux du post-partum. Les troubles pelvi-périnéaux du post-partum sont fréquents mais régressent spontanément la plupart du temps. L’incontinence urinaire dont la prévalence est proche de 40 % au cours de la grossesse régresse spontanément dans 85 % des cas à 3 mois du post-partum. En cas de persistance des symptômes, la rééducation périnéale semble améliorer les symptômes au moins à court terme. L’incontinence anale, dont la prévalence varie de 4 à 39 % à 6 semaines du post-partum régresse aussi spontanément la plupart du temps. La rééducation périnéale semble également être efficace à court mais pas à long terme. La prévalence des prolapsus de stade 2 est de 15 à 20 % au 3e trimestre de grossesse et elle varie de 20 à 50 % dans le post-partum immédiat. Même si la majorité des patientes (90 %) ont encore une petite composante de prolapsus à 1 an, seules 10 % en sont gênées. L’expectative avec une réévaluation de la gêne à 1 an du post-partum semble être préférable et, en cas de persistance des symptômes, une rééducation périnéale est alors préconisée.

Resume Objectif L’objectif de ce travail etait d’emettre des recommandations de bonne pratique concernant l’antibioprophylaxie dans le cadre d’un BUD. Materiels et methodes Des recommandations ont ete elaborees par un groupe de pilotage multidisciplinaire avant d’etre validees par une methode de consensus formalisee par un groupe multidisciplinaire de 12 experts (groupe de cotation). Elles ont ensuite ete validees par un groupe de lecture (experts differents du groupe de cotation). Resultats La realisation d’un examen cytobacteriologique des urines (ECBU) avec antibiogramme est recommandee dans les jours precedant le BUD, pour tous les patients (Accord fort). Chez les sujets ne presentant pas de pathologie neurologique, les facteurs de risque d’infection urinaire apres BUD sont l’âge > 70 ans, les infections urinaires iteratives et un residu post-mictionnel > 100 ml. Chez les sujets ayant une pathologie neurologique, les facteurs de risque d’infection urinaire apres BUD sont les infections urinaires iteratives, le reflux vesico-ureteral, une pression vesicale premictionnelle elevee > 40 cmH2O. Si l’ECBU pre-BUD est sterile, en l’absence de facteur de risque d’infection urinaire, aucune antibioprophylaxie n’est recommandee (Accord fort). Si l’ECBU pre-BUD est sterile mais qu’il existe un ou plusieurs facteur(s) de risque d’infection urinaire, une antibioprophylaxie peut etre, ou non, proposee. Si une antibioprophylaxie est decidee, il est recommande de prescrire une prise unique de fosfomycine-trometamol (3 g par voie orale), deux heures avant le BUD (Accord fort). En cas de colonisation urinaire pre-BUD, une antibiotherapie peut etre, ou non, prescrite (indecision). Si une antibiotherapie est proposee, elle doit etre adaptee a l’antibiogramme de la (ou des) bacterie(s) identifiee(s) (Accord fort). Elle doit etre debutee la veille de l’examen, et etre interrompue apres celui-ci (Accord fort) (sauf pour la fosfomycine-trometamol pour laquelle une seule prise la veille du BUD est necessaire et suffisante) (Accord fort). En cas d’infection urinaire pre-BUD, celle-ci doit etre traitee et l’examen doit etre reporte (Accord fort). Les regles proposees ici n’ont pas a etre modifiees chez les patients porteurs de prothese de hanche ou de genou (Accord fort). Par ailleurs, aucune prophylaxie de l’endocardite infectieuse n’est necessaire, y compris chez les patients porteurs de cardiopathie valvulaire a haut risque (Accord fort). Conclusion Ces nouvelles recommandations devraient contribuer a harmoniser les pratiques et a limiter l’exposition aux antibiotiques. Niveau de preuve 4.

El diagnostico de incontinencia urinaria (IU) es clinico: la anamnesis diferencia una incontinencia urinaria de esfuerzo (IUE), una incontinencia urinaria de urgencia (IUU) (hiperactividad vesical) y una incontinencia urinaria mixta (IUM). Esta distincion es esencial, porque las estrategias terapeuticas son diferentes. La fisiopatologia es compleja y multifactorial. Es cierto que el embarazo, el parto, la edad, un cierto grado de predisposicion genetica tisular y el sobrepeso son factores de riesgo demostrados, pero todavia no se conocen los mecanismos precisos que conducen a la genesis de uno u otro tipo de incontinencia. Aparte de los raros casos en que se sospecha una enfermedad organica subyacente (neurologica o uroginecologica) y despues de haber descartado una infeccion urinaria y un residuo posmiccional, puede proponerse un tratamiento de primera linea sin exploracion urodinamica previa. En la IUE, se recomienda la reeducacion (ejercicios de contraccion voluntaria de los musculos perineales) de entrada, en ocasiones asociada a una reduccion ponderal. En la hiperactividad vesical, la reeducacion (tecnicas conductuales, ejercicios de contraccion muscular y electroestimulacion) y los anticolinergicos (con o sin estrogenos topicos despues de la menopausia) constituyen los tratamientos de primera linea, en ocasiones asociados a una reduccion ponderal. En caso de fracaso de un tratamiento de primera linea, esta indicada una exploracion urodinamica. En la IUE, tras el fracaso de la reeducacion, se propone una intervencion quirurgica con colocacion de un cabestrillo suburetral (CSU). En caso de fracaso, se discuten otras alternativas: inyecciones/balones parauretrales y esfinter artificial. En la hiperactividad vesical, en caso de fracaso de los anticolinergicos, se puede proponer a la paciente una neuromodulacion (sacra o del ciatico popliteo interno) o inyecciones intradetrusorianas de toxina botulinica. Sea cual sea el tipo de incontinencia, se puede proponer a las mujeres que presentan una IU durante el embarazo o en el posparto una reeducacion, que se ha mostrado eficaz en estas dos indicaciones. En cambio, esta reeducacion no parece tener un efecto protector de larga duracion.

Objective Although placement of a retropubic mid-urethral slings (MUS) is one of the gold standard surgical treatments for stress urinary incontinence, new devices are poorly evaluated before marketing. We compared TVT-EXACT™ (TVT-E), a new device expected to reduce bladder injuries, with the historically described bottom-to-top TVT™ (TVT). Study design This retrospective study compared TVT-E ( n = 49) and TVT ( n = 49). The main outcomes were the prevalence of complications (bladder injuries, immediate postoperative pain, perioperative complications, etc.) and the short-term success rate (no reported urinary leakage and negative cough test) of both MUSs. Results Minimum follow-up was 12 months. The characteristics of the two groups were comparable. The prevalence of bladder injury for TVT-E and TVT was 8% and 6%, respectively ( p = 1). The intensity of immediate postoperative pain (VAS/100) was lower following TVT-E than after TVT (8.0 vs. 15.9, p = 0.01). The first post-void residual was increased in the TVT-E group (153.9 vs. 78.9 mL, p = 0.045), and there were more postoperative bladder outlet obstruction (BOO) symptoms in the TVT-E group (24% vs. 6%, p = 0.02). However, there was no difference when considering only de novo BOO (14% vs. 4%, p = 0.16). The prevalence of peri- and post-operative complications was equal in the two groups. The success rate was similar at 12 months of follow-up (80 vs. 82%, p = 1). Conclusion The prevalence of bladder injury was unchanged with TVT-EXACT™ compared with TVT™, but post-operative pain was decreased. The success rate of both retropubic MUSs was similar at 12 months of follow-up.

Objective To determine the post-partum management of women and their newborn whatever the mode of delivery. Material and methods The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. Results Because breastfeeding is associated with a decrease in neonatal morbidity (lower frequency of cardiovascular diseases, infectious, atopic or infantile obesity) (EL2) and an improvement in the cognitive development of children (EL2), exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (Professional consensus). In order to increase the rate of breastfeeding initiation and its duration, it is recommended that health professionals work closely with mothers in their project (grade A) and to promote breastfeeding on demand (grade B). There is no scientific evidence to recommend non-pharmacological measures of inhibition of lactation (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). For women aware of the risks of pharmacological treatment of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Whatever the mode of delivery, numeration blood count is not systematically recommended in a general population (Professional consensus). Anemia must be sought only in women with bleeding or symptoms of anemia (Professional consensus). The only treatment of post-dural puncture headache is the blood patch (EL2), it must not be carried out before 48 h (Professional consensus). Women vaccination status and their family is to be assessed in the early post-partum (Professional consensus). Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (Professional consensus). An analgesic multimodal protocol developed by the medical team should be available and oral way should be favored (Professional consensus) (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (Professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). Early postoperative rehabilitation is encouraged (Professional consensus). Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, after normal pregnancy and delivery (Professional consensus). Starting effective contraception later 21 days after delivery in women who do not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended (grade B). Rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long-term is not recommended (Expert consensus). Pelvic-floor rehabilitation using pelvic-floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C). Postpartum pelvic-floor rehabilitation is not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). The optimal time for maternity discharge for low risk newborn depends more on the organisation of the post-discharge follow up (Professional consensus). The months following the birth are a transitional period, and psychological alterations concern all parents (EL2). It is more difficult in case of psychosocial risk factors (EL2). In situations of proven psychological difficulties, the impact on the psycho-emotional development of children can be important (EL3). Among these difficulties, postpartum depression is the most common situation. However, the risk is generally higher in the perinatal period for all mental disorders (EL3). Conclusion Postpartum is, for clinicians, a unique and privileged opportunity to address the physical, psychological, social and somatic health of their patients.

Resume Objectif Etablir des recommandations concernant la reeducation perineale et abdominale du post-partum. Materiel et methode Revue exhaustive de la litterature concernant la reeducation perineale et abdominale du post-partum, etablissement de niveaux de preuve (NP) et de grades de recommandation selon la methodologie des recommandations pour la pratique clinique. Resultats La reeducation perineale par des exercices de contraction des muscles du plancher pelvien est recommandee pour traiter une incontinence urinaire persistante a 3 mois du post-partum (grade A), quel que soit le type d’incontinence. Au moins 3 seances guidees par un therapeute sont recommandees, associees a des exercices realises au domicile. Cette reeducation du post-partum ameliore l’incontinence urinaire a court terme (1 an), mais pas a long terme (6–12 ans). La reeducation perineale precoce (dans les deux mois suivants l’accouchement) n’est pas recommandee (grade C). La reeducation perineale du post-partum chez les femmes presentant une incontinence anale est associee a une prevalence moindre de symptomes d’incontinence anale a court (1 an) (NP3) mais pas a long terme (6 et 12 ans) (NP3). La reeducation perineale du post-partum est recommandee pour traiter une incontinence anale du post-partum (grade C) mais ses resultats ne sont pas maintenus a moyen ou long terme. Aucun essai randomise n’a evalue la reeducation perineale chez des femmes asymptomatiques dans le but de prevenir une incontinence urinaire ou anale a moyen ou long terme. Elle n’est donc pas recommandee (accord professionnel). La reeducation perineale guidee par un therapeute n’est pas plus efficace (tant sur le plan anatomique que symptomatique) que de simples conseils de contraction volontaire des muscles du plancher pelvien pour prevenir/corriger a court terme (6 mois) un prolapsus persistant a 6 semaines du post-partum (NP2), qu’il existe ou non un defect du levator ani (NP3). La reeducation perineale du post-partum n’est pas associee a une diminution de la prevalence des dyspareunies a 1 an (NP3). La reeducation perineale du post-partum guidee par un therapeute n’est donc pas recommandee pour traiter ou prevenir un prolapsus (grade C) ou des dyspareunies (grade C). Aucun essai randomise n’a evalue l’effet de la reeducation perineale apres un episode de retention ou dysurie du post-partum, ni dans la prevention primaire de l’incontinence anale en cas de perinee complet, ni chez des patientes presentant une incontinence anale dans les suites d’un perinee complet. La reeducation n’est donc pas recommandee dans ces situations. Les appareils d’electrostimulation utilises isolement n’ont pas ete evalues dans ce contexte du post-partum (que la femme soit symptomatique ou non) ; ils ne sont donc pas recommandes (accord professionnel). Conclusion Une reeducation perineale du post-partum est recommandee en cas d’incontinence urinaire (grade A) ou anale (grade C) persistant a 3 mois de l’accouchement.

Objective To determine the effect of the use of auto-cross-linked hyaluronic acid (ACP) gel following hysteroscopic surgery on the prevention of intra-uterine adhesions (IUAs) and the pregnancy rate. Study design An observational retrospective study of 90 patients who underwent hysteroscopic removal of IUAs was conducted between 2008 and 2013 at a tertiary university care centre. Thirty-two patients received ACP gel during hysteroscopic removal of IUAs, and the remaining 58 patients did not receive ACP gel. Controls were matched to cases according to infertility and severity of IUAs using the American Society for Reproductive Medicine (ASRM) score. Four to six weeks after surgery, patients underwent diagnostic hysteroscopy to determine the re-occurrence of IUAs or the presence of adhesions. The patients were contacted by telephone to answer a questionnaire concerning their fertility. The main outcomes were pregnancy rate and postoperative IUAs. Results Pregnancy (viable or not) rates were not influenced by the use of ACP gel. The viable pregnancy rate was eight of 24 (33.3%) in the ACP gel group and 12 of 49 (24.5%) in the control group ( p =0.427). The mean interval between surgery and pregnancy was 11.8 [standard deviation (SD) 10.5] months in the ACP group compared with 13.4 (SD 14.1) months in the control group ( p =0.744). The mean ASRM score after surgery (hysteroscopic diagnosis at 4–6 weeks postoperatively) was equivalent in the two groups: 2.7 (SD 3.0) in the ACP gel group vs 2.6 (SD 3.2) in the control group ( p =0.854). The mean follow-up was 45.2 months (interquartile range 33.2–52.7), with a loss to follow-up of 25% in the ACP gel group compared with 15.5% in the control group ( p =0.817). Conclusion Application of ACP gel did not prevent recurrence of IUAs and was not associated with an increased pregnancy rate. ACP gel should be used with caution pending assessment in a randomized control trial in a larger population.