14 Dec 5th Irish Congress of Obstetrics, Gynaecology and Perinatal Medicine- EVB Sport Presents
The Irish Congress of Obstetrics, Gynaecology and Perinatal Medicine is held over 2 days every two years and includes sessions from the Continence Foundation of Ireland (CFI), Irish Perinatal Society, and Society for minimal access surgery. It was held in Galway this year and the CFI breakout session was on the first day.
However in the plenary talks, the standout speaker on the pelvic floor was Dr Maria Gyhagen, Consultant in , Obstetrics and Gynecology and Urogynecology from the University of Gothenburg, Sweeden. The ‘More of the full picture – the longterm consequences of childbirth on the pelvic floor’. Her interest is long term consequences of childbirth on pelvic floor function, which has seen little attention this side of the world. She spoke of the mechanisms behind pelvic floor damage: Stretching, Compression, Muscle and fascia rupture, Denervation, and Ischaemia. The huge Swedish population databases allow for an enormous amount of data to be available for mining and analysis.
This year she published a study of 14,335 women aged 40-64 years, and whether they had symptoms delivery. Incidences of urinary incontinence were 20.1, 30.1, and 43.0% respectively. She concluded that caesarean delivery compared to vaginal, was associated with a 30% reduction in urinary incontinence, and a 35-52% reduction in more severe grades of incontinence (both p<0.0001). Moreover, age was associated with an increase in urinary incontinence in all 3 groups. (Gyhagen M et al. 2019 Am J Obs Gynae 221: 322.e1-17)
Maria also referred to her Doctoral thesis completed in 2013 on symptomatic pelvic organ prolapse (sPOP) and urinary incontinence (UI), from which she published extensively. She examined the
●sPOP prevalence was higher after vaginal delivery compared to caesarean (14.6 versus 6.3%, OR 2.55) but no difference between elective and emergency caesarean.
●Episiotomy, vacuum extraction and second degree tear had a similar incidence of sPOP compared to spontaneous vaginal delivery without these.
●sPOP increased 3% with each unit increase of current BMI
●sPOP increased by 3% per 100g increase in birthweight
●Mothers <160com in height who had vaginal delivery of a baby weighing >/=4000g had a doubled prevalence of sPOP compared to mothers who had vaginal delivery of a baby weighing <4000g. (Gyhagen M al BJOG 2013 2:144-51)
She also referred to work on faecal incontinence, derived from the registry again: FI was significantly more common after vaginal (14.5%) than caesarean (10.6%) delivery, after 2nd degree or worse perineal tear. Interestingly, FI was lower after vaginal delivery with episiotomy (11.1%), and similar to that of caesarean. Once again, each unit increase in BMI increased the odds of FI by 6%. (Gyhagen M et al, Int J Urogynae. 2014:25: 1411-8)
Continence Foundation of Ireland
In the CFI breakout session, there were 2 original presentations: A survey of Irish female medical students’ understanding of pelvic floor function was presented by Leah Falvey: awareness and understanding were remarkably poor. Further research was presented by Sarah Kennedy on levels of pain experienced by women undergoing urodynamics pressure testing: the major finding was that anxiety played a large part.
EVB Sport Presentation
EVB Sport presented a summary of the evidence on support underwear on UI. The concept of a garment with pelvic floor support is relatively new, and postulated that the additional positive pressure would reduce leakage. Research on ‘Shaper’ underwear in Japan has demonstrated significant bladder neck elevation on MRI in women with stress UI (Ninomiya S et al 2014, Lower Urinary Tract Symptoms 6(2) 81-7). This year, an assessor-blinded randomised controlled trial of the same product demonstrated a comparable effect to pelvic floor muscle training (Okayama H et al, Int Urogyn J. 30(7) 1093-9).
EVB Sports’s 3 double blind crossover studies on the EVB product versus generic sportswear in exercising women with stress UI: conducted in 2014, 2015 and 2017, Royal College of Surgeons, Dublin City University, and Trinity College Dublin respectively. The number of women in the first was too small to achieve significance, but volumes of leakage were reduced. In the DCU study, both confidence ratings and the number of women reporting no leakage were significantly higher wearing EVB shorts. More than four-fifths of women in the TCD work found EVB shorts helped them to feel confident, supported and secure while exercising for at least 30 minutes twice per week, even though they leaked urine, compared to less than half using the other shorts. Confirmatory evidence of efficacy for UI is urgently required from larger studies: if forthcoming, the potential benefit offered by a low-cost readily available tool to the wider non-exercising female population with urinary incontinence is enormous.
The Mechanics of EVB Sport
The discussion centred around mechanisms of efficacy of EVB, and whether there has been any experience with use for prolapse. It was clear that several uro- and general gynaecologists and physiotherapists had experience of EVB in their patients: there were several urologists present who were not familiar with the product or concept, and neither had Dr Gyhagen.
Mesh surgery current position
Dr Suzanne O’Sullivan (Urogynaecologist, University Hospital Cork) presented a review of the current position with mesh repairs of the vagina. She and her urogynaecology colleagues were tasked by the Chief Medical Officer to draw up recommendations on the use of mesh in vaginal repair, and removal in the face of complications. Essentially the situation is that no further meshes are being inserted. Furthermore removal of a mesh is known to be potentially difficult and risky: centres are to be designated where expertise on removal should be optimised. As yet it is unclear how these centres should be identified and where they should be.
Dr Linda Brubaker, Professor of Obs/Gynae and Reproductive Sciences at University of California,San Diego presented on Clinician Resilience and Well being. This was a talk relevant to any electronic and screen input, risk management, regulation and accreditation, to name a very few, all of which take from precious time spent with patients. Burnout is all-too-common. She spoke of the importance of ‘time out’ in the working day, even if it is a minute between patients, and approaching clinical time as a series of one-to-one interactions. ‘Multitasking’ is an illusion, in that one or more of the tasks will be done suboptimally if one is juggling. Vacations, and having them planned ahead, are critical. She uses meditation daily to reduce the clutter in her brain, and to destress. She spoke of the importance of colleagues, and pulling one another up if your colleague appears to be drowning in work.