Neurophysiology in urogynaecology

Abstract

In this issue of the International Urogynecology Journal, there is a focus on neurophysiology in urogynaecology. Neurophysiological studies have provided considerable advances in our understanding of the pathophysiology of pelvic floor disorders including urinary incontinence and pelvic organ prolapse. These studies have shown that there is a neurogenic basis for stress incontinence [1] and uterovaginal prolapse [2] caused by vaginal delivery as well as other associated factors of weakness of the pelvic floor muscles and connective tissue. A study by Kenton et al. [3] again confirms the value of neurological investigations in the study of pelvic floor disorders. Using concentric needle electromyography, they showed that women with stress incontinence had poorer urethral innervation than continent controls. They also found that there were significant neuropathic changes with ageing which is consistent with lower urethral pressures and decreasing numbers and diameter of striated muscles fibres of the urethral sphincter and pubococcygeus muscle with increasing age.Although neurophysiological investigations have contributed to our understanding of causation of urinary incontinence and prolapse, they have not to date been shown to have a significant role in the routine investigation and management of female urinary incontinence or uterovaginal prolapse. With this in mind, we have asked David Vodušek to provide an overview of the role of neurophysiological investigations in urogynaecology today. In his review [4], he discusses what neurophysiological tests tell us about nerves and muscles and what neurological investigations we should perform and when.Chronic pelvic pain in women is a common and difficult problem affecting one in five women, with most not having a clearly defined cause [5]. Many women date their pain back to gynaecological surgery, so not surprisingly, this is also an area of high medical litigation and anxiety to pelvic surgeons. The study of Possover et al. [6] in this issue reports on 95 consecutive women with pelvic pain and/or bladder or bowel dysfunction following pelvic prolapse surgery. These women underwent laparoscopic exploration and neurolysis for what the authors considered to be iatrogenic pelvic nerve injury. The authors' conclusions are that prolapse surgery is a common cause of nerve injury and pelvic pain, which is frequently underdiagnosed but can be successfully treated surgically.Many women with chronic pelvic pain often present having already been told that their pain is caused by surgical nerve injury or entrapment. This explanation is very attractive to women with chronic pain as it gives them a clear understandable cause for their pain and hope that it can be successfully treated by surgical exploration; but how true is this? The causes, diagnosis and management of pudendal neuralgia have recently been reviewed by Stav et al. [7] including the role of neurophysiological studies and nerve decompression surgery. Neurophysiological tests were considered to have a low diagnost...

Laparoscopic Sacrocolpopexy Mesh Removal for Persistent Lumbosacral and Right-sided Gluteal Pain Possibly Caused by Nerve “entrapment”

“…It was di cult to determine whether to perform laparoscopic exploration and remove the mesh before surgery because few similar cases have been reported [6]. The incidence of nerve entrapment after LSC with mesh is unclear, and the nerve injury incidence has been underestimated [7]; thus, the risks associated with the use of mesh in the treatment of pelvic organ prolapse and stress incontinence should be well documented. Some scholars have tried to perform LSC without mesh, which has some effects, but relevant data are limited, and randomized multicenter studies are needed to draw de nitive conclusions [8].…”