Clinical evaluation after incontinence surgery and dehisced perineal tears : effects on women's pelvic floor health

<p dir="ltr">Introduction</p><p dir="ltr">The prevalence of symptoms resulting from pelvic floor dysfunction are high and urinary incontinence in particular is a burden for the individual as well as for society. Stress urinary incontinence (SUI), which is the most common type of incontinence in women, has since the late 1990s been treated with mid-urethral slings (MUS). Rising concern about risks, complications, and long-term outcome have guided research in this direction. With obesity emerging as a growing global health issue, a known risk factor for urinary incontinence, alongside the aging population in many countries, the need for a clear rationale for treating various types of urinary incontinence is evident. Additionally, the awareness of consequences of a dehisced perineal tear after childbirth has increased. The need for evidence-based best clinical practices is essential to prevent more women from experiencing pelvic floor dysfunction.</p><p dir="ltr">The aims of this thesis were to evaluate dyspareunia and pelvic pain following MUS surgery, to investigate the impact of BMI on long-term outcome after MUS surgery, and to compare these findings with a control group of women who had not undergone the procedure. Another objective was to explore optimal treatment strategies for dehisced second-degree perineal tears after childbirth.</p><p dir="ltr">Methods and results</p><p dir="ltr">Studies I, II, and III were registry-based investigations that included all women who underwent MUS surgery in Sweden and were registered in the Swedish National Quality Register of Gynecological Surgery (GynOp) between 2006 and 2010. In total 2421 women were analysed, 1562 women after retropubic MUS and 859 women after transobturator MUS. In study I dyspareunia, pelvic pain and sexual function, assessed by PISQ-12 were compared between the two surgical techniques, no differences were found. Study II investigated the impact of BMI at the time of MUS surgery on long-term outcomes, specifically focusing on subjective SUI. A higher BMI was significantly associated with lower cure rates both one year and ten years postoperatively. In study III a reference group was added to the GynOp cohort. The comparison of pelvic pain and lower urinary tract symptoms (LUTS) revealed that women aged 50 years or older who had undergone MUS surgery reported significantly more pelvic pain and LUTS than women who had never received a MUS.</p><p dir="ltr">Study IV was a multicentre randomised controlled trial that examined the treatment of dehisced second-degree perineal tears. Early resuturing was compared to conventional conservative management with secondary healing. 141 women were included within 14 days after childbirth. In the final analysis 134 women were included, follow-ups were performed after two and four weeks and healing was significantly faster in the resuturing group. While no differences were observed between the groups in terms of pain or breastfeeding, the resuturing group demonstrated significantly better psychological well-being, as measured by the EPDS scale, at the first follow-up.</p><p dir="ltr">Conclusions</p><p dir="ltr">Dyspareunia, pelvic pain, and sexual function after MUS surgery do not differ between retropubic and transobturator MUS techniques.</p><p dir="ltr">An elevated BMI at the time of MUS surgery is associated with a lower cure rate.</p><p dir="ltr">Pelvic pain and LUTS appear to be more prevalent in women over the age of 50 who have undergone MUS surgery at least ten years earlier, compared to those who have not.</p><p dir="ltr">In the treatment of dehisced second-degree perineal tears after childbirth, early resuturing appears to be more effective than conservative management in reducing healing time, without adversely affecting pain levels, breastfeeding, or psychological well-being.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Lundmark Drca A,</b> Alexandridis V, Andrada Hamer M, Teleman P, Westergren Söderberg M, Ek M. Dyspareunia and pelvic pain: comparison of mid-urethral sling methods 10 years after insertion. Int Urogynecol J. 2024 Jan;35(1). Epub 2023 Jul 10. <a href="https://doi.org/10.1007/s00192-023-05585-3" rel="noreferrer" target="_blank">https://doi.org/10.1007/s00192-023-05585-3</a></p><p dir="ltr">II. <b>Lundmark Drca A,</b> Westergren Söderberg M, Ek M. Obesity as an independent risk factor for poor long-term outcome after mid-urethral sling surgery. Acta Obstet Gynecol Scand. 2024 Aug. Epub 2024 Jun 11. <a href="https://doi.org/10.1111/aogs.14883" rel="noreferrer" target="_blank">https://doi.org/10.1111/aogs.14883</a></p><p dir="ltr">III. <b>Lundmark Drca A,</b> Alexandridis V, Teleman P, Westergren Söderberg M, Ek M. Pelvic pain and lower urinary tract symptoms; long-term comparison between women with and without mid-urethral sling insertion. Acta Obstet Gynecol Scand. 30 September 2025. [Accepted]</p><p dir="ltr">IV. <b>Lundmark Drca A</b> and Golmann D, Bergman I, Strindfors G, Westergren Söderberg M, Ek M. A randomised trial of resuturing versus expectancy for dehisced second-degree perineal tears: Early Healing, Pain, and Depressive Symptoms. [Manuscript]</p>