Sexual abuse rates in the general female population range between 15% and 25%, and sexual abuse is known to have a long-term impact on a woman’s health. The aim of this study was to report the prevalence of sexual abuse history in women presenting to clinicians for pelvic floor disorders (PFD) and to determine whether a history of sexual abuse is associated with a specific type of PFD.
We conducted a retrospective chart review of new urogynecology patients seen at the University of New Mexico Hospital. All women underwent a standardized history and physical examination and completed symptom severity and quality-of-life measures. Univariate and multivariable analyses were conducted to determine which PFDs were associated with a history of sexual abuse among women with and without a history of sexual abuse.
A total of 1899 new urogynecology patients with complete information were identified from January 2007 and October 2011; 1260 (66%) were asked about a history of sexual abuse. The prevalence of sexual abuse was 213/1260 (17%). In the multivariable analysis, only chronic pelvic pain remained significantly associated with a history of sexual abuse.
A history of sexual abuse is common among women with PFDs, and these women were more likely to have chronic pelvic pain.
pelvic floor disorders; sexual abuse
Pelvic floor disorders (PFDs) can impact sexual function. This summary provides an overview of the impact of stress urinary incontinence and pelvic organ prolapse and their treatments on sexual function. In general, interventions that successfully address PFDs will generally improve sexual function as well. However, there are patients whose sexual function will remain unchanged despite treatment, and a small but significant minority who will report worsened sexual function following treatment for their pelvic floor dysfunction.
To determine the longer-term efficacy and safety of initiating treatment for urgency-predominant urinary incontinence (UUI) in women diagnosed using a simple questionnaire rather than an extensive evaluation.
Women completing a 12-week randomized controlled trial of fesoterodine therapy for UUI diagnosed by questionnaire were invited to participate in a 9-month open label continuation study. UUI and voiding episodes were collected using voiding diaries. Participant satisfaction was measured by questionnaire. Safety was assessed by measurement of post void residual volume and adverse event monitoring; if necessary, women underwent specialist evaluation. Longitudinal changes in UUI and voiding episodes were evaluated using linear mixed models adjusting for baseline.
Of the 567 women completing the randomized trial, 498 (87.8%) took at least one dose of medication during this open label study. Compared to the enrollment visit in the randomized trial, fesoterodine was associated with a reduction in total incontinence episodes/day and urgency incontinence episodes/day at the end of the open label study [adjusted mean (standard error (SE)) 4.6 (0.12) to 1.2 (0.13) and 3.9 (0.11) to 0.9 (0.11) respectively, p-value<.0001 for both]. Most women were satisfied with treatment (89%, 92%, and 93% at 3, 6, and 9 months). Twenty-six women experienced 28 serious adverse events, one of which was considered possibly treatment-related. Twenty-two women had specialist evaluation: 5 women’s incontinence was misclassified by the 3IQ; none experienced harm due to misclassification.
Using a simple validated questionnaire to diagnose and initiate treatment for UUI in community dwelling women is safe and effective, allowing timely treatment by primary care practitioners.
Primary Care; Treatment; Urgency Urinary Incontinence
Introduction and hypothesis
To determine if prolapse symptom severity and bother varies among non-Hispanic white, Hispanic, and Native American women with equivalent prolapse stages on physical examination.
This was a retrospective chart review of new patients seen in an academic urogynecology clinic from January 2007 to September 2011. Data were extracted from a standardized intake form, including patients’ self-identified ethnicity. All patients underwent a Pelvic Organ Prolapse Quantification (POPQ) examination and completed the Pelvic Floor Distress Inventory-20 (PFDI-20) with its Pelvic Organ Prolapse Distress Inventory (POPDI) subscale.
Five hundred and eighty-eight new patients were identified with pelvic organ prolapse. Groups did not differ by age, prior prolapse, and/or incontinence surgery, or sexual activity. Based on POPDI scores, Hispanic and Native American women reported more bother compared with non- Hispanic white women with stage 2 prolapse (p<0.01). Level of bother between Hispanic and Native American women with stage 2 prolapse (p=0.56) was not different. In subjects with ≥ stage 3 prolapse, POPDI scores did not differ by ethnicity (p=0.24). In multivariate stepwise regression analysis controlling for significant factors, Hispanic and Native American ethnicity contributed to higher POPDI scores, as did depression.
Among women with stage 2 prolapse, both Hispanic and Native American women had a higher level of bother, as measured by the POPDI, compared with non-Hispanic white women. The level of symptom bother was not different between ethnicities in women with stage 3 prolapse or greater. Disease severity may overshadow ethnic differences at more advanced stages of prolapse.
Ethnicity; Hispanic; Native American; Pelvic organ prolapse; Symptom bother
To assess the effect of the initial visit with a specialist on disease understanding among Spanish-speaking women with pelvic floor disorders.
Spanish-speaking women with referrals suggestive of urinary incontinence (UI) and/or pelvic organ prolapse (POP) were recruited from public urogynecology clinics. Patients participated in a health literacy assessment and interview before and after their physician encounter. All interviews were analyzed using Grounded Theory qualitative methods.
Twenty-seven women with POP (N=6), UI (N=11), and POP/UI (N=10) were enrolled in this study. The mean age was 55.5 years and the majority of women had marginal levels of health literacy. From our qualitative analysis, three concepts emerged. First, was that patients had poor understanding of their diagnosis before and after the encounter regardless of how extensive the physician’s explanation or level of Spanish-proficiency. Secondly, patients were overwhelmed with the amount of information given to them. Lastly, patients ultimately put their trust in the physician, relying on them for treatment recommendations.
Our findings emphasize the difficulty Spanish-speaking women with low health literacy have in understanding information regarding pelvic floor disorders. In this specific population, the physician has a major role in influencing patients’ treatment decisions and helping them overcome fears they may have about their condition.
Pelvic Prolapse; Incontinence; Qualitative Methods; Health Literacy; Disease Understanding
Describe differences in sexual activity and function in women with and without pelvic floor disorders (PFDs).
Heterosexual women > 40 years of age who presented to either Urogynecology or general gynecology clinics at 11 clinical sites were recruited. Women were asked if they were sexually active with a male partner. Validated questionnaires and Pelvic Organ Prolapse Quantification (POPQ) examinations assessed urinary incontinence (UI), fecal incontinence (FI) and/or pelvic organ prolapse (POP). Sexual activity and function was measured by the Female Sexual Function Index (FSFI). Student’s t-tests were used to assess continuous variables; categorical variables were assessed with Fisher’s exact test and logistic regression. Univariate and multivariate analyses were used to assess the impact of PFDs on FSFI total and domain scores.
505 women met eligibility requirements and consent for participation. Women with and without PFDs did not differ in race, BMI, co-morbid medical conditions, or hormone use. Women with PFDs were slightly older than women without PFDs (55.6 + 10.8 vs. 51.6 + 8.3 years, P <0.001); all analyses were controlled for age. Women with PFDs were as likely to be sexually active as women without PFDs (61.6 vs. 75.5%, P=0.09). There was no difference in total FSFI scores between cohorts (23.2 + 8.5 vs. 24.4 + 9.2, P= 0.23) or FSFI domain scores (all p = NS).
Rates of sexual activity and function are not different between women with and without PFDs.
anal incontinence; pelvic organ prolapse; questionnaires; sexual function; urinary incontinence
The purpose of our study was to evaluate barriers in communication and disease understanding among office staff and interpreters when communicating with Spanish-speaking women with pelvic floor disorders.
We conducted a qualitative study to evaluate barriers to communication with Spanish-speaking women with pelvic floor disorders among office staff and interpreters. Sixteen office staff and interpreters were interviewed; interview questions focused on experiences with Spanish-speaking patients with pelvic floor disorders in the clinic setting. Interview transcripts were analyzed qualitatively using grounded theory methodology.
Analysis of the interview transcripts revealed several barriers in communication as identified by office staff and interpreters. Three major classes were predominant: patient, interpreter, and system-related. Patient-related barriers included 1) a lack of understanding of anatomy and medical terminology and inhibited discussions due to embarrassment. Provider-related barriers included poor interpreter knowledge of pelvic floor vocabulary and the use of office staff without interpreting credentials. System-related barriers included poor access to information. From these preliminary themes, an emergent concept was revealed: it is highly likely that Spanish-speaking women with pelvic floor disorders have poor understanding of their condition due to multiple obstacles in communication.
There are many levels of barriers to communications with Latinas treated for pelvic floor disorders, arising from the patient, interpreter, and the system itself. These barriers contribute to a low level of understanding of their diagnosis, treatment options, and administered therapies.
pelvic prolapse; urinary incontinence; disease understanding; underserved Latinas
Introduction and hypothesis
To determine whether fecal incontinence (FI) is associated with sexual activity and to compare sexual function in women with and without FI.
We conducted a retrospective chart review of all new patients seen in an academic urogynecology clinic. Women who reported fecal incontinence, as defined by loss of fecal material on the Wexner scale, were compared with those without fecal incontinence. We compared sexual activity and Pelvic Organ Prolapse Incontinence Sexual Questionnaire-12 (PISQ-12) scores between groups.
In our population of women with pelvic floor disorder, 588 women reported FI compared with 527 who did not. On multivariate analysis, FI was not associated with sexual activity status, but was associated with worsened PISQ-12 scores (p<0.001). PISQ-12 item analysis found that women with FI reported more dyspareunia, fear, and avoidance of sexual activity with greater partner problems (all p <0.05) than women without FI.
Women with FI were as likely to engage in sexual relations as women without FI; however, sexually active women with FI had poorer sexual function than those without FI.
Fecal incontinence; Sexual activity; Sexual function
Introduction and hypothesis
The objective of this study was to compare complementary and alternative medicine (CAM) use in women with and without pelvic floor disorders (PFD).
We conducted a survey of women presenting to a specialty urogynecology (Urogyn) and gynecology (Gyn) clinic that examined demographic data, CAM use, and the presence of PFD (validated questionnaires). T tests, Fisher’s exact tests, and logistic regression were used for analysis. To detect a 20% difference between groups, 234 Urogyn and 103 Gyn patients were needed.
Participants included 234 Urogyn and 103 Gyn patients. Urogyn patients reported more CAM use than Gyn patients, even when controlled for differences between groups (51% vs. 32%, adjusted p=0.006). Previous treatment (61% vs. 39%, adjusted p<0.001) and increased number of PFD was associated with increased CAM use (adjusted p=0.02).
Women with PFD use CAM more frequently than women without PFD.
Complementary alternative medicine; Fecal incontinence; Pelvic floor disorders; Pelvic organ prolapse; Urinary incontinence
Few studies on health literacy and disease understanding among women with pelvic floor disorders have been published. We conducted a pilot study to explore the relationship between disease understanding and health literacy, age, and diagnosis type among women with urinary incontinence and pelvic organ prolapse.
Study subjects were recruited from urology and urogynecology specialty clinics based on a chief complaint suggestive of urinary incontinence or pelvic prolapse. Subjects completed questionnaires to assess symptom severity and health literacy was measured using the Test of Functional Health Literacy in Adults. Patient-physician interactions were audiotaped during the office visit. Immediately afterwards, patients were asked to describe diagnoses and treatments discussed by the physician and record them on a checklist, with follow-up phone call where the same checklist was administered 2–3 days later.
A total of 36 women with pelvic floor disorders, aged 42–94, were enrolled. We found that health literacy scores decreased with increasing age; however, all patients had low percentage recall of their pelvic floor diagnoses and poor understanding of their pelvic floor condition despite high health literacy scores. Patients with pelvic prolapse appeared to have worse recall and disease understanding than patients with urinary incontinence.
High health literacy as assessed by the TOFHLA may not correlate with patients' ability to comprehend complex functional conditions such as pelvic floor disorders. Lack of understanding may lead to unrealistic treatment expectations, inability to give informed consent for treatment, and dissatisfaction with care. Better methods to improve disease understanding are needed.
pelvic floor disorders; health literacy; incontinence; pelvic organ prolapse
The purpose of this study was to evaluate clinical outcomes associated with the initiation of treatment for urgency-predominant incontinence in women diagnosed by a simple 3-item questionnaire.
We conducted a multicenter, double-blinded, 12-week randomized trial of pharmacologic therapy for urgency-predominant incontinence in ambulatory women diagnosed by the simple 3-item questionnaire. Participants (N = 645) were assigned randomly to fesoterodine therapy (4-8 mg daily) or placebo. Urinary incontinence was assessed with the use of voiding diaries; postvoid residual volume was measured after treatment.
After 12 weeks, women who had been assigned randomly to fesoterodine therapy reported 0.9 fewer urgency and 1.0 fewer total incontinence episodes/day, compared with placebo (P ≤ .001). Four serious adverse events occurred in each group, none of which was related to treatment. No participant had postvoid residual volume of ≥250 mL after treatment.
Among ambulatory women with urgency-predominant incontinence diagnosed with a simple 3-item questionnaire, pharmacologic therapy resulted in a moderate decrease in incontinence frequency without increasing significant urinary retention or serious adverse events, which provides support for a streamlined algorithm for diagnosis and treatment of female urgency-predominant incontinence.
antimuscarinic therapy; diagnostic algorithm; fesoterodine; urgency incontinence
To evaluate whether patient determined goal achievement is associated with pessary continuation.
Patients identified goals they wished to achieve from pessary use. Patients were asked whether they continued pessary use and if goals were met 6–12 months later. Goals were divided into eight categories. Fisher’s exact test was used to evaluate categorical variables, t-tests for continuous variables, and regression methods to calculate odds ratios (OR).
Eighty women enrolled in the study. Sixty-four had follow-up data. Goals commonly listed were bladder (36%), activity (20%), general health (13%), and prolapse related (11%). Thirty-four women continued and 30 discontinued pessary use. Women who continued pessary use were more likely to meet one or two goals (OR 17.5, 21.1 and 95% CI 4.8–64.4, 5.7–78.9, respectively)
Patient goals are variable and subjective. However, when assessed for achievement, they’re associated with pessary continuation. Women who attain self-determined goals are likely to continue pessary use.
Pessary; outcome; goals; quality of life
Introduction and Objective
To determine incidence, remission and predictors of change in urinary incontinence in women ≥ 50 in a racially diverse population.
Subjects were women ≥50 with 4 year follow-up incontinence information in the Health and Retirement Study. Women with Any UI (AUI) and Severe UI (SVUI) were evaluated. Repeated measures logistic regression determined predictors of progression to and improvement of SVUI.
11,591 women were evaluated. AUI 4 year cumulative incidence was 12.7%–33.8% (5th vs. 9th decades). SVUI incidence was lower but also increased with age. Among the predictors of improvement in SVUI were age (9th vs. 5th decade OR=6.06), ethnicity (Black vs. White OR=.57). Improvement of SVUI (45.8% overall) decreased with age (9th vs. 5th decade OR=.12).
SVUI incidence increased and remission decreased with age. Ethnicity and age predicted SVUI progression while age predicted improvement. Rates of the latter were high, particularly in younger patients.
Urinary Incontinence; Incidence; Remission; Predictors
Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative delivery.
A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the Present Pain Intensity (PPI) and Visual Analog Scale (VAS) components of the validated short form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines.
At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 +/− 1.61 vs 1.48 +/− 1.40; P< 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, P= 0.002) than women with mild or no trauma. By 3 months average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non-Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model only trauma group and length of active pushing predicted pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on level of pain at discharge beyond its effect on the incidence of major trauma.
Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.
childbirth; perineal pain; genital tract trauma; labor management
To identify abnormal function of the limbic cortex (LC) in response to urinary urgency among patients with Overactive Bladder (OAB) using brain functional MRI (fMRI)
5 OAB subjects and 5 Controls underwent bladder filling and rated urgency sensations while fMRI measured activation in discrete volumes (voxels) within the brain. Changes in brain activation were related to bladder distension and individual subject’s rating of urgency via multiple regression analysis. Beta weights from regression equations were converted into percent signal change (PSC) for each voxel and PSC compared to the null hypothesis using T-tests. Significance threshold of P<.05 was applied along with a cluster size threshold of.32 ml (5 voxels).
OAB patients showed increased brain activation in LC, specifically the insula (IN) and Anterior Cingulate Gyrus (ACG), associated with increased urgency. Urgency sensations during low volumes were associated with bilateral IN activation in OAB subjects (7,621 voxels right IN, 4,453 voxels left IN, mean beta weights .018 +/− .014 and .014 +/− .011) Minimal activation was present in Controls (790 voxels right IN, beta weight =.010 +/− .007). Urgency sensations during high volumes were associated with bilateral ACG activation in OAB subjects (2,304 voxels right IN, 5,005 voxels left IN, mean beta weights of 005 +/− .003 and 004+/−.003) without activation in Controls.
Urinary urgency in patients with OAB is associated with increased activation of the LC. This activation likely represents abnormal processing of sensory input in brain regions associated with emotional response to discomfort.
OAB; fMRI; urinary urgency
The purpose of this study was to determine the effect of posterior repair (PR) on sexual function in patients who have undergone incontinence and/or pelvic reconstructive surgery.
A cohort study of women who underwent incontinence and/or prolapse surgery was performed. Participants completed the pelvic organ prolapse urinary incontinence sexual questionnaire (PISQ) before and after the operation. PISQ scores were compared between women who underwent PR and women who did not.
Of 73 study participants, 30 women underwent PR; 43 women did not (no PR). Although there was no difference in dyspareunia between groups pre-op, dyspareunia prevalence post-op was significantly lower in the no PR group. Preoperative PISQ scores were similar between groups. After the operation, both groups significantly improved their PISQ scores, without a difference between groups.
Although the incidence of dyspareunia differed between PR and no PR groups, overall improvement in sexual function was reflected in improved total PISQ scores that occurred irrespective of PR performance.
dyspareunia; incontinence; posterior repair; prolapse; sexual function
Introduction and hypothesis
This study seeks to determine if total vaginal length (TVL) or genital hiatus (GH) impact sexual activity and function.
Heterosexual women≥40 years were recruited from urogynecology and gynecology offices. TVL and GH were assessed using the Pelvic Organ Prolapse Quantification exam. Women completed the Female Sexual Function Index (FSFI) and were dichotomized into either normal function (FSFI total>26) or sexual dysfunction (FSFI≤26).
Five hundred five women were enrolled; 333 (67%) reported sexual activity. While sexually active women had longer vaginas than women who were not active (9.1 cm±1.2 versus 8.9 cm±1.3, p=0.04), significance was explained by age differences. GH measurements did not differ (3.2 cm±1.1 versus 3.1 cm±1.1, p=0.58). In sexually active women, TVL was weakly correlated with FSFI total score, but GH was not. TVL and GH did not differ between women with normal FSFI scores and those with sexual dysfunction.
Vaginal size did not affect sexual activity or function.
Sexual activity; Sexual function Vaginal anatomy; Total vaginal length; Genital hiatus; Questionnaires
(1) To systematically collect and organize into clinical categories all outcomes reported in trials for abnormal uterine bleeding (AUB); (2) to rank the importance of outcomes for patient decision making; and (3) to improve future comparisons of effects in trials of AUB interventions.
Study Design and Setting
Systematic review of English-language randomized controlled trials of AUB treatments in MEDLINE from 1950 to June 2008. All outcomes and definitions were extracted and organized into major outcome categories by an expert group. Each outcome was ranked “critically important,” “important,” or “not important” for informing patients’ choices.
One hundred thirteen articles from 79 trials met the criteria. One hundred fourteen different outcomes were identified, only 15 (13%) of which were ranked as critically important and 29 (25%) as important. Outcomes were grouped into eight categories: (1) bleeding; (2) quality of life; (3) pain; (4) sexual health; (5) patient satisfaction; (6) bulk-related complaints; (7) need for subsequent surgical treatment; and (8) adverse events.
To improve the quality, consistency, and utility of future AUB trials, we recommend assessing a limited number of clinical outcomes for bleeding, disease-specific quality of life, pain, sexual health, and bulk-related symptoms both before and after treatment and reporting satisfaction and adverse events. Further development of validated patient-based outcome measures and the standardization of outcome reporting are needed.
Menorrhagia; Dysfunctional uterine bleeding; Leiomyomata; Hysterectomy; Uterine artery embolization; Endometrial ablation
Changes in sexual function are common in postpartum women. In this comparative, descriptive study, a prospective cohort of midwifery patients consented to documentation of genital trauma at birth and assessment of sexual function three months postpartum. The impact of spontaneous genital trauma on postpartum sexual function was the focus of the study. Trauma was categorized into minor trauma (no trauma or 1st degree perineal or other trauma that was not sutured) or major trauma (2nd, 3rd, or 4th degree lacerations or any trauma that required suturing). Women who underwent episiotomy or operative delivery were excluded. Fifty eight percent (326/565) of enrolled women gave sexual function data; of those, 276 (85%) reported sexual activity since delivery. Seventy percent (193) of women sustained minor trauma and 30% (83) sustained major trauma. Sexually active women completed the Intimate Relationship Scale (IRS), a 12 item questionnaire validated as a measure of postpartum sexual function. Both trauma groups were equally likely to be sexually active. Total IRS scores did not differ between trauma groups nor did complaints of dyspareunia. However, for two items, significant differences were demonstrated: women with major trauma reported less desire to be held, touched, and stroked by their partner than women with minor trauma, and women who required perineal suturing reported lower IRS scores than women who did not require suturing.
Objective To compare the costs of a protocol of active management of labor with those of traditional labor management. Design Cost analysis of a randomized controlled trial. Methods From August 1992 to April 1996, we randomly allocated 405 women whose infants were delivered at the University of New Mexico Health Sciences Center, Albuquerque, to an active management of labor protocol that had substantially reduced the duration of labor or a control protocol. We calculated the average cost for each delivery, using both actual costs and charges. Results The average cost for women assigned to the active management protocol was $2,480.79 compared with an average cost of $2,528.61 for women in the control group (P = 0.55). For women whose infant was delivered by cesarean section, the average cost was $4,771.54 for active management of labor and $4,468.89 for the control protocol (P = 0.16). Spontaneous vaginal deliveries cost an average of $27.00 more for actively managed patients compared with the cost for the control protocol. Conclusions The reduced duration of labor by active management did not translate into significant cost savings. Overall, an average cost saving of only $47.91, or 2%, was achieved for labors that were actively managed. This reduction in cost was due to a decrease in the rate of cesarean sections in women whose labor was actively managed and not to a decreased duration of labor.