Introduction: Pessary use is the preferred non-surgical treatment option for female pelvic organ prolapse. As pessaries can be used chronically to alter pelvic floor anatomy, consideration of shortand long-term complications is important in patient management. We systematically reviewed articles describing the complications of pessary use to determine frequency and severity. Methods: A systematic search via MEDLINE and PubMed using the key terms "complications," "pessary," "pelvic organ prolapse," "side effects" was conducted for the years 1952 to 2014 inclusively. Selected articles cited in the publications identified were also considered. Only full-text material published in English was reviewed. All pessary-related complications described were collated; overall frequency within case reports and case series were calculated and severity was graded using the Clavien-Dindo classification. Results: In total, 61 articles met the inclusion criteria. The most common complications reported were vaginal discharge/vaginitis, erosion, and bleeding. Complications were related to pessary shape and material, and duration in situ. Clavien-Dindo classification of complication severity found that all 5 grade levels were attributed to pessary use; serious grade 4 and 5 complications included cancer, adjacent organ fistula and death. Conclusion: There are few detailed reports of complications of pessary use relative to the estimated frequency of pessary use worldwide. Prospective studies documenting complications by shape, material, and size, and objectively classifying complication severity are required. As serious grade 4 and 5 complications of pessary use occur, further development of clinical follow-up guidelines for long-term pessary users is justified.
We provide an overview of advanced imaging techniques currently being explored to gain greater understanding of the complexity of stress urinary incontinence (SUI) through better definition of structural anatomic data. Two methods of imaging and analysis are detailed for SUI with or without prolapse: 1) open magnetic resonance imaging (MRI) with or without the use of reference lines; and 2) 3D reconstruction of the pelvis using MRI. An additional innovative method of assessment includes the use of near infrared spectroscopy (NIRS), which uses non-invasive photonics in a vaginal speculum to objectively evaluate pelvic floor muscle (PFM) function as it relates to SUI pathology. Advantages and disadvantages of these techniques are described. The recent innovation of open-configuration magnetic resonance imaging (MRO) allows images to be captured in sitting and standing positions, which better simulates states that correlate with urinary leakage and can be further enhanced with 3D reconstruction. By detecting direct changes in oxygenated muscle tissue, the NIRS vaginal speculum is able to provide insight into how the oxidative capacity of the PFM influences SUI. The small number of units able to provide patient evaluation using these techniques and their cost and relative complexity are major considerations, but if such imaging can optimize diagnosis, treatment allocation, and selection for surgery enhanced imaging techniques may prove to be a worthwhile and cost-effective strategy for assessing and treating SUI. IntroductionAdvances in the diagnosis and treatment of female stress urinary incontinence (SUI) are being aided by the use of emerging technologies that offer greater understanding of the basic science underlying bladder disease.1 This is relevant given that female SUI affects 32-64% 2 of the female population and that 11.1% will need to undergo treatment or require surgery in their lifetime.3 In addition to providing novel insights on the causal etiology, new technologies offer elements able to enhance diagnosis and tools relevant to optimizing therapy for a large number of women worldwide. 4Pregnancy and childbirth are the important causes of pelvic floor injury. Subpopulations of patients are recognized within the spectrum of SUI. SUI can be observed in nulliparous women 4.7% of the time. 4 During pregnancy SUI is reported in up to 50% of women, and additional insults to the pelvic floor are known to occur during labour and delivery. 5Epidemiological studies have identified elements related to labour and delivery that influence the frequency of symptoms; however, it is still unclear how much pregnancy contributes to the pathology, whether the predominant effects occur during labour and delivery, and what is the relevance of other risk factors, e.g., maternal age, body weight, genetics, and lifestyle. 4 Currently, it is believed that partial denervation of the pelvic floor and lineal injury to pelvic floor muscles and connective tissue are caused by mechanical and hormonal changes during pregnancy...
In pelvic organ prolapse (POP), posture and gravity impact organ position and symptom severity. The advanced magnet configuration in open magnetic resonance imaging (MRO) allows patients to be imaged when sitting and standing, as well in a conventional supine position. This study evaluated if sitting and standing MRO images are relevant as a means of improving quantification of POP because they allow differences in organ position not seen on supine imaging to be identified. Methods: Forty women recruited from a university urogynecology clinic had MRO imaging (0.5 T scanner) with axial and sagittal T2-weighted pelvic scans obtained when sitting, standing, and supine. Pelvic reference lines were used to quantify the degree of POP, and the relevance of imaging position on the detection of POP compared. Results: Images from 40 participants were evaluated (20 with POP and 20 asymptomatic controls). Our results indicate that the maximal extent of prolapse is best evaluated in the standing position using H line, M line, mid-pubic line, and perineal line as reference lines to determine POP. Conclusions: MRO imaging of symptomatic patients in a standing position is relevant in the quantification of POP. Compared with supine images, standing imaging identifies that greater levels of downward movement in the anterior and posterior compartments occur, presumably under the influence of posture and gravity. In contrast, no appreciable benefit was afforded by imaging in the sitting position, which precluded use of some reference lines due to upward movement of the anorectal junction.
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