I recently spent an intense week at the IUGA/CFA Conference in Brisbane. Sorry to all the Twitter followers hanging out for tweet updates…not sure if it was because there was no official tweet tag but not many people were actually tweeting. Things kept popping into my head and then the next paper would start and it was hard to find time to tweet and catch up…so here it all is – the lost tweets from IUGA/CFA…but I might give myself the luxury of more than 140 characters on some of them!
The absolute best quote from the whole week came from Dr Helena Frawley in her final statement for the negative team in the debate PELVIC FLOOR EXERCISES ARE OVER-RATED when she defined IUGA as “In yoU Go Again”…a very clever play on words, and guess what, the negative team had a resounding win over the affirmative (with acknowledgement to both sides with all speakers presenting factually and entertainingly)
My main impressions and take home messages (in no particular order ) :
- We need to question the results of research. It can be presented in a “cup half full” or a “cup half empty” way. For example, if a study shows a treatment intervention resulted in a 60% cure rate, this is what the researchers will report. It doesn’t however report the 40% who weren’t cured, and are still left with their problem.
We also need to carefully analyse the statistics presented with research- it seems that you can work magic with statistics!
- Just because something is statistically significant doesn’t mean it is clinically applicable
- Professor Malone-Lee; “Is change due to history? passage of time? or due to our treatment? Perception , you can see what you want to.”
- “research only answers the questions posed of it “ was a quote I heard ( apologies as I did not record who made it)
- There were many studies comparing mesh procedures. The do’s and don’ts ; the ins and outs; the pros and cons. There was a debate “The FDA got it wrong” with both sides presenting good cases ( sadly misconstrued in some tweets sent from people not present but working on slides photographed during the debate and sent electronically. When debating , you have to present your alloted argument side, hence you look for information and research to back up your argument. I think one has to be present and hear the tone of the debate, and the comments made, in order to give an opinion – not go by snippets of information sent to you and make assumptions to suit your particular viewpoint.
- I was left with no doubt, from research presented, that mesh gives an anatomically better repair success (particularly in the anterior compartment) BUT the outstanding stats from one study were that there was a 33% mesh contraction rate and 23% rate of dyspareunia. Kudos to Dr Linda Cardozo ……. who received spontaneous applause from the audience when she challenged the validity and I think morality of thinking that this sort of trade-off is acceptable. Another study gave a 10% dyspareunia rate whilst a Cochrane review gave 12%…….Which leads to my next tweet snippet:
- Patients care about their symptoms and quality of life NOT their POP-Q score which is so often used as the gold standard of success or cure for a procedure (with or without mesh involvement) .
- Re-operation rates are high for POP surgery.
- Hispareunia is a term coined for male pain/injury to penis from intercourse with partner who has mesh erosion.
- Arguments for mesh suggested that surgeon experience was the biggest independent variable.
- We need to improve patient knowledge to enable them to participate in their clinical management
- There were many studies using US in 2,3 and 4D looking at such things as levator hiatus ballooning in women with varying conditions such as POP, PVD (provoked vestibulodynia), pre and post surgery, during and after childbirth. It was fascinating to see these images and see this non-inasive technique being used more and more for research and assessment.
- PFD (pelvic floor dysfunction) which includes any of urinary, faecal, sexual and prolapse symptoms were found to be high in pre-pregnancy nulliparous women. These women were 2-4 x more likely to be symptomatic postnatally than those who were symptom free prenatally making it the highest risk factor for postnatal PFD.
- Is POP tissue more rigid due to older patient?
- Is POP a cause or effect? It is the mechanical failure of tissue. Is this intrinsic, genetic or acquired?
- Are tissue changes (thickening) at POP site due to increased mechanical load or an accomodation to a decrease in support from elsewhere?
- Pelvic floor fibroblasts respond to biomechanical and mechanical forces – do different POP levels show different fibroblast changes?
- Dissatisfaction of recurrence post-op vs pain should be looked at. Mesh may give a better result anatomically than native tissue repairs (particularly in the anterior compartment) but not better pain wise.
- Outcome measures for POP surgery need to be defined – some use QOL, some use anatomical markers like POP-Q
- A woman’s lifetime risk of developing POP is 10-20%
- Lifetime risk for POP surgery is 11%.
- Pessary use as a conservative Rx option. Trial had 62% success rate and of those 66% were still using their pessary (Ramsay et al) Erosion rate was higher with those using eostrogen – erosion difficult to predict and not prevented by use of eostrogen
- Dietz US the way I do it :
- Clinical examinations can give lots of false positives. Uterine prolapse often not picked up. Rectoceles often misdiagnosed at which level it is and lots of pathology can hide behind a rectocele- e.g. enterocele, intersusception.
- Prolapse is a hernia
- Palpate a levator avulsion anteriorly- locate urethra, slide to side- if you feel bone then levator avulsion on that side.
- Levator trauma is the most substantial predictor of recurrence after prolapse surgery
- Hiatus ballooning is an independent risk factor for POP recurrence after surgery
- Forceps triples the risk of avulsion
- Increased hiatal area and levator ani avulsion = increased incidence of POP
- Outcomes are what patients care about
- POP-Q is too strict at 0-1 as a measure of treatment success: 40% of normal women without POP symptoms have POP-Q stage 2. by ICS definition POP-Q 2+ is a recurrence.
- From the PFMT debate: watchful waiting is reasonable as only 13% of POP get worse over 5 years. What is the long term history of POP? so why rush into surgery.
- Amongst risk factors for POP obesity, constipation and IAP (intra-abdominal pressure) changes can all be changed. Risk factors that can’t are age,parity and connective tissue.
- Forceps deliveries have a 20x risk of having POP surgery
- High BMI, older age , 4+ babies are risk factors for POP
- There are cellular and mechanical factors in who does/doesn’t develop POP
- How is Levator Ani injured during birth- dennervation? compression? stretching? We should treat it like a sports injury: Diagnosis/treatment/rehabilitation/ prevention.
- Can pudendal nerve blocks be used to paralyse and relax the levator muscles- would this reduce injuries?
- There is a biological rationale for PFMT – constrict the levator hiatus and increase urethral closing pressure. Morphological changes occur in the muscle ( Bo )
- SUI :
At any age : 10% nulliparous , 16% C/S, 21% vaginal delivery
50-64 y.o : 15.2% nulliparous, 28.6% C/S , 30% of vaginal delivery
There is a 3% annual increase risk per year of age for SUI
8-9 C/S are done to avoid one case of SUI
- Less training is needed to maintain than to build muscle strength.
- Forceps deliveries have a high risk for faecal incontinence.
- Myofascial pelvic pain in IC ( interstitial cystitis) may be due to a generalised pain syndrome and is seen co-morbidly with other pain conditions such as IBS and Fibromyalgia
- There are often hypermyalgia points in Obturator Internus, Levator Ani and perineum in IC patients- we should be doing a musculoskeletal evaluation with IC patients
- 30% of women DEPRESSED pelvic floor when given a TrA ( transversus Abdominis) cue alone
Whew…well there are some of the snippets from notes taken. Remembering that these are just impressions and statements taken from papers presented. They do give food for thought and the aim is hopefully to make us all think about what we read, not always believe everything we read in research – look at the data and how it has been collected, analysed and presented.
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