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1.  Incidence of Female Urethral Diverticulum: A Population-Based Analysis and Literature Review 
Introduction and Hypothesis
Urethral diverticulum (UD) is a protrusion of the urethra through the periurethral fascia. We aimed to determine the population-based incidence of female UD.
Using the records-linkage system of the Rochester Epidemiology Project (REP), we identified women 18 years and older with a new diagnosis of UD in Olmsted County, Minnesota, from January 1, 1980, through December 31, 2011. We also identified cases meeting the same criteria diagnosed at Mayo Clinic, regardless of county of residency. Incidence rates were calculated and trends for changes in incidence over time were tested. We conducted a systematic search of the MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science, and Scopus databases from inception through March 30, 2013, to identify published reports of UD incidence or prevalence.
We identified 164 incidence cases, including 26 women residing in Olmsted County. Age-adjusted annual incidence of UD in Olmsted County was 17.9 per 1,000,000 women (<0.02%) per year (95% CI, 10.9–24.9). We observed a trend for increased incidence during the past 3 decades (P=.03). In our literature review, only 7 studies included an estimate of incidence or prevalence of UD; these estimates ranged from 6.4 per 1,000,000 per year (<0.01%) having surgical intervention related to UD to a 4.7% rate of UD diagnosed in asymptomatic women admitted for gynecologic or obstetric issues.
In this population-based study, female UD was a rare disease, affecting fewer than 20 per 1,000,000 women (<0.02%) per year.
PMCID: PMC4317296  PMID: 23857063
Urethra; diverticulum; urogynecology; urology
2.  [No title available] 
PMCID: PMC3982298  PMID: 24008367
3.  Surgical Preparation: Are Patients “Ready” for Stress Urinary Incontinence Surgery? 
International urogynecology journal  2013;25(1):10.1007/s00192-013-2184-x.
Introduction and Hypothesis:
Patient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life.
The ValUE trial compared the effect of pre-operative urodynamic studies to a standardized office evaluation on outcomes of SUI surgery at one year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured with a 5-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment’s effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ).
Based on PPQ Question 11, 4 out of 5 (81%) of women reported they “agreed” or “strongly agreed” that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ) (Spearman r = 0.13, p = 0.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (rs=0.11, p = 0.02) and larger PGI-S improvement (increase) (p=0.008).
Approximately half (48%) of women “strongly agreed” that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied although surgical outcomes did not differ.
PMCID: PMC3833875  PMID: 23912506
Stress Incontinence; Mid-urethral Sling; Randomized Trial; Urodynamics; Satisfaction; Surgical Outcomes
4.  Comparison of pelvic muscle architecture between humans and commonly used laboratory species 
International urogynecology journal  2014;25(11):1507-1515.
Introduction and hypothesis
Pelvic floor muscles (PFM) are deleteriously affected by vaginal birth, which contributes to the development of pelvic floor disorders. To mechanistically link these events, experiments using animal models are required, as access to human PFM tissue is challenging. In choosing an animal model, a comparative study of PFM design is necessary, since gross anatomy alone is insufficient to guide the selection.
Human PFM architecture was measured using micromechanical dissection and then compared with mouse (n=10), rat (n=10), and rabbit (n=10) using the Architectural Difference Index (ADI) (parameterizing a combined measure of sarcomere length-to-optimal-sarcomere ratio, fiber-to-muscle-length ratio, and fraction of total PFM mass and physiological cross-sectional area (PCSA) contributed by each muscle). Coccygeus (C), iliocaudalis (IC), and pubocaudalis (PC) were harvested and subjected to architectural measurements. Parameters within species were compared using repeated measures analysis of variance (ANOVA) with post hoc Tukey's tests. The scaling relationships of PFM across species were quantified using least-squares regression of log-10-transformed variables.
Based on the ADI, rat was found to be the most similar to humans (ADI = 2.5), followed by mouse (ADI = 3.3). When animals' body mass was regressed against muscle mass, muscle length, fiber length, and PCSA scaling coefficients showed a negative allometric relationship or smaller increase than predicted by geometric scaling.
In terms of muscle design among commonly used laboratory animals, rat best approximates the human PFM, followed by mouse. Negative allometric scaling of PFM architectural parameters is likely due to the multifaceted function of these muscles.
PMCID: PMC4264598  PMID: 24915840
Pelvic muscles; Muscle architecture; Animal model
5.  Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments 
International urogynecology journal  2012;23(11):1483-1494.
The objective of this work was to collect and summarize relevant literature on the anatomy, histology, and imaging of apical support of the upper vagina and the uterus provided by the cardinal (CL) and uterosacral (USL) ligaments. A literature search in English, French, and German languages was carried out with the keywords apical support, cardinal ligament, transverse cervical ligament, Mackenrodt ligament, parametrium, paracervix, retinaculum uteri, web, uterosacral ligament, and sacrouterine ligament in the PubMed database. Other relevant journal and textbook articles were sought by retrieving references cited in previous PubMed articles. Fifty references were examined in peer-reviewed journals and textbooks. The USL extends from the S2 to the S4 vertebra region to the dorsal margin of the uterine cervix and/or to the upper third of the posterior vaginal wall. It has a superficial and deep component. Autonomous nerve fibers are a major constituent of the deep USL. CL is defined as a perivascular sheath with a proximal insertion around the origin of the internal iliac artery and a distal insertion on the cervix and/or vagina. It is divided into a cranial (vascular) and a caudal (neural) portions. Histologically, it contains mainly vessels, with no distinct band of connective tissue. Both the deep USL and the caudal CL are closely related to the inferior hypogastric plexus. USL and CL are visceral ligaments, with mesentery-like structures containing vessels, nerves, connective tissue, and adipose tissue.
PMCID: PMC4258694  PMID: 22618209
Apical supports; Uterosacral ligament; Cardinal ligament; Anatomy; Histology; Imaging
6.  The introduction of laparoscopic sacral colpopexy to a fellowship training program 
International urogynecology journal  2013;24(11):1877-1881.
Introduction and Hypothesis
Minimally invasive sacral colpopexy has increased over the past decade with many senior physicians adopting this new skillset. However, skill acquisition at an academic institution in the presence of post-graduate learners is not well described. This manuscript outlines the introduction of laparoscopic sacral colpopexy to an academic urogynecology service that was not performing minimally invasive sacral colpopexies while also defining a surgical learning curve.
The first 180 laparoscopic sacral colpopexies done by 4 attending urogynecologists from January 2009 to December 2011 were retrospectively analyzed. The primary outcome was operative time. Secondary outcomes included conversion to laparotomy, estimated blood loss, and intra- and postoperative complications. Linear regression was used to analyze trends in operative times. Fisher’s exact test compared surgical complications and counts of categorical variables.
Mean total operative time was 250 ± 52 minutes (range 146–452) with hysterectomy and 222 ± 45 (range 146–353) for sacral colpopexy alone. When compared to the first 10 cases performed by each surgeon, operative times in subsequent groups decreased significantly with a 6 to 16.3% reduction in overall times. There was no significant difference in the rate of overall complications regardless of the number of prior procedures performed (p=0.262).
The introduction of laparoscopic sacral colpopexy in a training program is safe and efficient. The reduction in operative time is similar to published learning curves in teaching and non-teaching settings. Introducing this technique does not add additional surgical risk as these skills are acquired.
PMCID: PMC4060525  PMID: 23549650
Laparoscopy; Learning curve; Prolapse; Sacral colpopexy
International urogynecology journal  2014;25(11):1483-1489.
Vitamin D is an important micronutrient in muscle function. We hypothesize that vitamin D deficiency may contribute to fecal incontinence symptoms by affecting the anal continence mechanism. Our goal is to characterize the association of vitamin D deficiency as a variable affecting fecal incontinence symptoms and its impact on health-related quality of life.
This case-control study included women seen at a tertiary care referral center. Subjects were identified as having had a serum vitamin D level obtained within a year of their visit. Cases were women presenting for care for fecal incontinence symptoms. Controls were women without any pelvic floor symptoms presenting to the same clinical site for general gynecology care. Cases completed the Modified Manchester Health Questionnaire and the Fecal Incontinence Severity Index to measure symptom severity and burden on quality of life.
Among the 31 cases and 81 controls, no demographic or medical differences existed between the groups. Women with fecal incontinence had lower vitamin D levels (mean 29.2±12.3 cases vs. 35±14.1 ng/ml controls respectively, p=0.04). The odds of vitamin D deficiency were higher in women with fecal incontinence compared to controls [OR 2.77, 95% CI (1.08–7.09)]. Among cases, women with deficient vitamin D (35%) had higher Modified Manchester Health Questionnaire scores, indicating greater fecal incontinence symptom burden [51.3±29.3 (vitamin D deficient) vs. 30±19.5 (vitamin D sufficient), p=0.02]. No differences were noted for fecal incontinence severity, p=0.07.
Vitamin D deficiency is prevalent in women with fecal incontinence and may contribute to patient symptom burden.
PMCID: PMC4192075  PMID: 24807423
vitamin D; pelvic floor; fecal incontinence
8.  Risk Factors for Urinary Tract Infection following Incontinence Surgery 
International urogynecology journal  2011;22(10):1255-1265.
Introduction and Hypothesis
The purpose of this study is to describe risk factors for post-operative urinary tract infection (UTI) the first year after stress urinary incontinence surgery.
Multivariable logistic regression analyses were performed on data from 1,252 women randomized in two surgical trials, Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr) and Trial Of Mid-Urethral Slings (TOMUS).
Baseline recurrent UTI (rUTI; ≥ 3 in 12 months) increased the risk of UTI in the first 6 weeks in both study populations, as did sling procedure and self-catheterization in SISTEr, and bladder perforation in TOMUS. Baseline rUTI, UTI in first 6 weeks, and PVR > 100 cc at 12 months were independent risk factors for UTI between 6 weeks and 12 months in the SISTEr population. Few (2.3-2.4%) had post-operative rUTI, precluding multivariable analysis. In women with pre-operative rUTI, successful surgery (negative cough stress test) at 1 year did not appear to decrease the risk of persistent rUTI.
Pre-operative rUTI is the strongest risk factor for post-operative UTI.
PMCID: PMC4184412  PMID: 21560012
Urinary tract infection; Stress urinary incontinence surgery; Recurrent urinary tract infection; Risk factors
9.  Pre-operative Clinical, Demographic and Urodynamic Measures Associated with Failure to Demonstrate Urodynamic Stress Incontinence in Women Enrolled in Two Randomized Clinical Trials of Surgery for Stress Urinary Incontinence 
The unexpected absence of urodynamic stress incontinence (USI) in women planning surgery for stress urinary incontinence (SUI) is a challenge to surgeons. We examined the prevalence and clinical and demographic factors associated at baseline (pre-operatively) with the unexpected absence of USI among study participants of two multi-center randomized clinical trials of surgery for treatment of SUI.
Women with stress incontinence symptoms and positive stress tests on physical examination enrolled in two separate clinical trials comparing the autologous fascial sling with the Burch suspension (SISTEr trial), and the retropubic mid urethral sling compared to the transobturator mid urethral sling (TOMUS), were evaluated for USI preoperatively. The association of clinical, demographic and urodynamic parameters was examined in women without USI in univariable and multivariable analyses.
Overall, 144 of 1233 women (11.7%) enrolled in the two studies did not show USI. These women had a significantly lower mean volume at maximum cystometric capacity than those with USI (347.5 vs. 395.8 in SISTEr, p = 0.012), (315.2 vs. 358.2 in TOMUS, p = 0.003), and a lower mean number of daily accidents reported on a three day diary (2.2 vs 2.7 in SISTEr, p = 0.030) (1.7 vs 2.7 in TOMUS, p < 0.001). Additionally, those without demonstrable USI were more likely to have POPQ stage III/IV (31.7% vs 14.4% in SISTEr, p = 0.002), (15.5% vs 6.9% in TOMUS, p = 0.025). Severity of SUI as recorded on Urogenital Distress Inventory correlated strongly with the presence of USI in both studies.
We observed that about one of out eight women planning surgery for SUI does not show USI. Severity of stress incontinence and Stage 3/4 pelvic organ prolapse were strongly associated with the unexpected absence of USI. A diminished urodynamic bladder capacity among women who did not display USI may reflect an inability to reach the limits of capacity during urodynamics, at which these women normally leak.
PMCID: PMC4169424  PMID: 22669421
10.  On pelvic reference lines and the MR evaluation of genital prolapse: a proposal for standardization using the Pelvic Inclination Correction System 
International urogynecology journal  2013;24(9):1421-1428.
Five midsagittal pelvic reference lines have been employed to quantify prolapse using MRI. However, the lack of standardization makes study results difficult to compare. Using MRI scans from 149 women, we demonstrate how use of existing reference lines can systematically affect measurements in three distinct ways: in oblique line systems, distances measured to the reference line vary with antero-posterior location; soft issue-based reference lines can underestimate organ movement relative to the pelvic bones; and systems defined relative to the MR scanner are affected by intra- and interindividual differences in the pelvic inclination angle at rest and strain. Thus, we propose a standardized approach called the Pelvic Inclination Correction System (PICS). Based on bony structures and the body axis, the PICS system corrects for variation in pelvic inclination, at rest of straining, and allows for the standardized measurement of organ displacement in the direction of prolapse.
PMCID: PMC3986860  PMID: 23640002
Female; MRI; Pelvic floor; Pelvic organ prolapse; Pelvic reference lines; Pelvic tilt
11.  Alterations in pelvic floor muscles and pelvic organ support by pregnancy and vaginal delivery in squirrel monkeys 
International urogynecology journal  2011;22(9):1109-1116.
Introduction and hypothesis
The objective of this study was to measure the effects of pregnancy and parturition on pelvic floor muscles and pelvic organ support.
Levator ani, obturator internus, and coccygeus (COC) muscle volumes and contrast uptake were assessed by MRI of seven females prior to pregnancy, 3 days, and 4 months postpartum. Bladder neck and cervix position were measured dynamically with abdominal squeezing.
The sides of three paired muscles were similar (p>0.66). COC volumes were greater (p<0.004) after parturition than before pregnancy or after recovery. COC contrast uptake increased (p<0.02) immediately after delivery. Bladder neck position both in the relaxed state and abdominal pressure descended (p<0.04) after delivery and descended further (p<0.001) after recovery. Cervical position in the relaxed state before delivery was higher (p<0.001) than postpartum but was unchanged (p=0.50) with abdominal pressure relative to delivery.
In squirrel monkeys, coccygeus muscles demonstrate the greatest change related to parturition, and parturition-related bladder neck descent seems permanent.
PMCID: PMC4128415  PMID: 21567260
MRI; Pelvic floor muscles; Pelvic organ prolapse; Parturition; Squirrel monkey
12.  Are bony pelvis dimensions associated with levator ani defects? A case–control study 
International urogynecology journal  2013;24(8):1377-1383.
Introduction and hypothesis
Bony pelvis dimensions have been shown to differ in women with and without pelvic floor dysfunction. The goal of this study was to determine whether bony pelvis dimensions are different when comparing women with severe bilateral levator ani defects (LAD) with those with normal muscles.
This is a secondary analysis of a case–control study comparing women with and those without pelvic organ prolapse. Subjects underwent pelvic organ prolapse quantification (POP-Q) examination and were classified as either having prolapse or being normal. All underwent pelvic magnetic resonance imaging (MRI). Levator defects were assessed based on the muscles’ appearance on imaging and subjects were stratified into two groups—women with normal muscles (n=99) and women with severe bilateral LAD (n=50). Bony pelvis dimensions were measured via MRI pelvimetry. The subpubic angle, interspinous and intertuberous diameters, and the sacrococcygeal joint-to-infrapubic point (SCIPP) lengths were compared.
Both groups had similar demographics. The SCIPP length was 2.5 % (3 mm) shorter in women with severe LAD than in those without defects (P=0.02). The SCIPP measured 4 % (5 mm) less in women with prolapse and severe LAD than in subjects with prolapse but normal muscles (P=0.01). Logistic regression identified SCIPP length and history of forceps delivery as being independent predictors of severe bilateral LAD.
Severe bilateral LAD are associated with shorter SCIPP length and forceps-assisted vaginal delivery.
PMCID: PMC3982292  PMID: 23306771
Bony pelvis; Levator ani defects; Magnetic resonance imaging; Pelvic floor disorders; Pelvic organ prolapse
13.  Post-reduction stress urinary incontinence rates in posterior versus anterior pelvic organ prolapse: a secondary analysis 
International urogynecology journal  2013;24(8):1355-1360.
Stress incontinence with vaginal prolapse reduction is less common in women with posterior-predominant prolapse (rectocele) compared with those with anterior-predominant prolapse (cystocele).
This was a secondary analysis of a cohort of prospectively enrolled women with symptomatic pelvic organ prolapse at or beyond the hymen and prolapse-reduced stress urinary incontinence (SUI) testing. Subjects were included if they had anterior- or posterior-predominant prolapse with at least a 1 cm difference in pelvic organ prolapse quantification (POP-Q) points Ba and Bp (N=214). We evaluated the prevalence and risk factors of post-reduction SUI between the two groups.
Comparing posterior (n=45) and anterior (n=169) prolapse groups, we identified similar rates of post-reduction SUI (posterior: 6/45, 13.3 %; anterior: 18/169, 10.7 %; p= 0.52) and SUI without reduction (posterior: 4.4 %; anterior: 11.2 %; p=0.26). Maximum prolapse size was slightly larger in anterior than in posterior patients (+3.1 vs +2.0 cm beyond the hymen, p=0.001), while a higher proportion of posterior subjects reported a prior hysterectomy (p=0.04). Among posterior subjects, lower maximum urethral closure pressure values (MUCP; p=0.02) were associated with post-reduction SUI. In contrast, among anterior-predominant prolapse, larger prolapse measured at POP-Q point Ba (p=0.003) and maximum POP-Q measurement (p=0.006) were each associated with higher rates of post-reduction SUI and were highly correlated with each other (R=0.90).
We observed similar rates of post-reduction SUI in women with anterior- and posterior-predominant pelvic organ prolapse. Factors affecting the anterior and posterior prolapse groups differed, suggesting different mechanisms of continence protection. These findings suggest that reduction incontinence testing for operative planning would be as relevant to posterior-predominant prolapses as it is to anterior prolapse.
PMCID: PMC4078259  PMID: 23306769
Post-reduction; Occult stress urinary incontinence; Rectocele
14.  Iatrogenic genitourinary fistula: an 18-year retrospective review of 805 injuries 
International Urogynecology Journal  2014;25(12):1699-1706.
Introduction and hypothesis
Genitourinary fistula poses a public health challenge in areas where women have inadequate access to quality emergency obstetric care. Fistulas typically develop during prolonged, obstructed labor, but providers can also inadvertently cause a fistula when performing obstetric or gynecological surgery.
This retrospective study analyzes 805 iatrogenic fistulas from a series of 5,959 women undergoing genitourinary fistula repair in 11 countries between 1994 and 2012. Injuries fall into three categories: ureteric, vault, and vesico-[utero]/-cervico-vaginal. This analysis considers the frequency and characteristics of each type of fistula and the risk factors associated with iatrogenic fistula development.
In this large series, 13.2 % of genitourinary fistula repairs were for injuries caused by provider error. A range of cadres conducted procedures resulting in iatrogenic fistula. Four out of five iatrogenic fistulas developed following surgery for obstetric complications: cesarean section, ruptured uterus repair, or hysterectomy for ruptured uterus. Others developed during gynecological procedures, most commonly hysterectomy. Vesico-[utero]/-cervico-vaginal fistulas were the most common (43.6 %), followed by ureteric injuries (33.9 %) and vault fistulas (22.5 %). One quarter of women with iatrogenic fistulas had previously undergone a laparotomy, nearly always a cesarean section. Among these women, one quarter had undergone more than one previous cesarean section.
Women with previous cesarean sections are at an increased risk of iatrogenic injury. Work environments must be adequate to reduce surgical error. Training must emphasize the importance of optimal surgical techniques, obstetric decision-making, and alternative ways to deliver dead babies. Iatrogenic fistulas should be recognized as a distinct genitourinary fistula category.
PMCID: PMC4234894  PMID: 25062654
Cesarean section; Genitourinary fistula; Hysterectomy; Iatrogenic; Ureteric injury
15.  Architectural design of the pelvic floor is consistent with muscle functional subspecialization 
Introduction and hypothesis
Skeletal muscle architecture is the strongest predictor of a muscle’s functional capacity. The purpose of this study was to define the architectural properties of the deep muscles of the female pelvic floor (PFMs) to elucidate their structure–function relationships.
PFMs coccygeus (C), iliococcygeus (IC), and pubovisceral (PV) were harvested en bloc from ten fixed human cadavers (mean age 85 years, range 55–102). Fundamental architectural parameters of skeletal muscles [physiological cross-sectional area (PCSA), normalized fiber length, and sarcomere length (Ls)] were determined using validated methods. PCSA predicts muscle-force production, and normalized fiber length is related to muscle excursion. These parameters were compared using repeated measures analysis of variance (ANOVA) with post hoc t tests, as appropriate. Significance was set to α=0.05.
PFMs were thinner than expected based on data reported from imaging studies and in vivo palpation. Significant differences in fiber length were observed across PFMs: C=5.29±0.32 cm, IC=7.55±0.46 cm, PV=10.45±0.67 cm (p<0.001). Average Ls of all PFMs was short relative to the optimal Ls of 2.7 µm of other human skeletal muscles: C=2.05±0.02 µm, IC=2.02±0.02 µm, PC/PR=2.07±0.01 µm (p=<0.001 compared with 2.7 µm; p=0.15 between PFMs, power=0.46). Average PCSA was very small compared with other human muscles, with no significant difference between individual PFMs: C=0.71±0.06 cm2, IC=0.63±0.04 cm2, PV=0.59±0.05 cm2 (p=0.21, power=0.27). Overall, C had shortest fibers, making it a good stabilizer. PV demonstrated the longest fibers, suggesting that it functions to produce large excursions.
PFM design shows individual muscles demonstrating differential architecture, corresponding to specialized function in the pelvic floor.
PMCID: PMC4104205  PMID: 23903821
Muscle architecture; Muscle function; Pelvic floor
16.  Laparoscopic extravesical vesicovaginal fistula repair: our technique and 15-year experience 
Introduction and hypothesis
Two types of laparoscopic vesicovaginal fistula (VVF) repairs, the traditional transvesical (O’Conor) and extravesical techniques, dominate the literature. We present our 15-year experience of primary and recurrent cases of VVF utilizing an extravesical technique, which we first described in 1999.
An IRB approved retrospective study revealed 44 female patients with either primary or recurrent VVF. Laparoscopic extravesical repair was performed without an omental flap in the majority of cases. A three-layer closure technique was performed utilizing a double-layer bladder closure and a single-layer vaginal closure followed by bladder testing. A suprapubic catheter was utilized for 2–3 weeks postoperatively for bladder decompression.
A review of our experience reveals a 97 % (32 out of 33) cure for primary VVF and 100 % (11 out of 11) rate for recurrent fistulas, with an overall cure rate of 98 % (43 out of 44) at a mean follow-up of 17.3 months (range 3–64). An omental flap was not utilized in 98 % of patients (43 out of 44), with a success rate of 98 % (42 out of 43). The mean estimated blood loss was 39 mL (range 0–450), mean hospital stay was 1.1 days (range 1–3), and none of the patients suffered any major intra- or postoperative complications. None of the patients required a conversion to open laparotomy.
Based upon our experience we believe that performing laparoscopic extravesical VVF repair using a three-layer closure technique without an interposition omentum is a safe, effective, minimally invasive technique with excellent cure rates in an experienced surgeon’s hands.
PMCID: PMC4328114  PMID: 25027019
Bladder fistula; Laparoscopic vesicovaginal fistula repair; O’Conor; Omental flap; Vesicouterine fistula; Vesicovaginal fistula
17.  Ethnicity and variations of pelvic organ prolapse bother 
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.
PMCID: PMC3922120  PMID: 23807143
Ethnicity; Hispanic; Native American; Pelvic organ prolapse; Symptom bother
18.  The prevalence of urinary incontinence in American Indian women from a South Dakota tribe 
Introduction and hypothesis
The purpose of this pilot study was to evaluate the prevalence and associated risk factors for urinary incontinence in a Northern Plains tribe of American Indian women.
The Urogenital Distress Inventory-Short Form was used to assess urinary incontinence in a sample of American Indian women from one tribe. This was a cross-sectional convenience sampling of 234 eligible participants. Participant’s ages ranged from 18 to 80 years. Stata/Se 9.1 software was used in statistical analysis.
The overall prevalence of urinary stress incontinence was 15.4%, urgency incontinence 2.14%, and mixed incontinence 20.5%. Both stress and urgency incontinence was found to be low in this sample population.
A reduced prevalence of stress and urgency incontinence is seen in our sample. Our study group showed a high prevalence of known risk factors associated with urinary incontinence. We intend to extend our study for further understanding of this patient population.
PMCID: PMC4059537  PMID: 22159561
American Indian women; National Health and Nutrition Examination Survey; Urinary incontinence
19.  A prospective study of a single-incision sling at the time of robotic sacrocolpopexy 
International Urogynecology Journal  2014;25(11):1541-1546.
Introduction and hypothesis
The objective of this study was to evaluate the efficacy and safety of the Miniarc Precise® single-incision sling (American Medical Systems, Minnetonka, MN, USA) placed at the time of a robotic sacrocolpopexy.
This was a prospective study of a single-incision suburethral sling placed at the time of robotic sacrocolpopexy in women with stress urinary incontinence (SUI) and pelvic organ prolapse. Primary outcome measure was cure at 1 year, defined objectively by a negative cough stress test (CST) and subjectively by a score of “0 or 1” on question 17 of the Pelvic Floor Distress Inventory (PFDI-20): “Do you experience urine leakage related to coughing/sneezing/laughing?” Secondary outcome measures included the change in Urinary Distress Inventory (UDI-6) and Urinary Impact Questionnaire (UIQ-7) scores at 1 year. All sling-related complications were reported. Paired Student’s t test and the Wilcoxon signed-rank test were used for statistical analysis.
One hundred and one patients were included between August 2010 and July 2012. One-year follow-up was available for 97 out of 101 patients (96 %). Objective cure was 90 % and subjective cure was 87 %. Baseline UDI-6 scores improved from 34.8 ± 25.1 to 6.7 ± 11.2 at 1 year (p < 0.001). Similarly, UIQ-7 scores improved from 21.1 ± 22.8 to 2.4 ± 8.2 at 1 year (p < 0.001). There were no intraoperative cystotomies, no mesh erosions, no sling revisions, and no cases of urinary retention. The retreatment rate for persistent SUI was 8 % (8 out of 97).
The addition of a single-incision suburethral sling at the time of robotic sacrocolpopexy in women with SUI resulted in an 87 % cure rate at 1 year.
PMCID: PMC4190456  PMID: 24894202
Pelvic organ prolapse; Robotic sacrocolpopexy; Single-incision sling; Stress urinary incontinence
20.  Validation of a bladder symptom screening tool in women with incontinence due to overactive bladder 
International Urogynecology Journal  2014;25(12):1655-1663.
Introduction and hypothesis
The Actionable Bladder Symptom Screening Tool (ABSST) was initially developed to identify patients with multiple sclerosis (MS) who could benefit from lower urinary tract assessment and treatment. Assessment of the measurement properties of the ABSST, including its ability to identify patients experiencing bladder symptoms related to overactive bladder (OAB), was undertaken in a general female population.
One hundred women completed the ABSST, OAB Questionnaire Short Form (OAB-q SF), and a patient global impression of severity (PGI-S) scale. Half of the sample had urgency urinary incontinence (UUI), while the other half did not. Descriptive statistics, reliability, and validity were examined, as was sensitivity and specificity of the previous cut-off score established in MS.
Fifty-three women with UUI/OAB and 47 controls took part (71.0 % Caucasian). Patients with UUI/OAB were older (54.6 vs 40.4 years), had a higher body mass index (31.1 vs 26.4 kg/m2), and more comorbid conditions. The Cronbach’s alpha reliability of ABSST was 0.90. High correlations with OAB-q SF Symptom Bother and Health Related Quality of Life (r = 0.83 and −0.81 respectively) supported concurrent validity. Using the PGI-S severity scores as a reference, the ABSST was able to distinguish patients with differing severity levels (known-group validity). Physician assessment of the need for further evaluation/treatment showed sensitivity (79 %) and specificity (98 %), supporting a cut-off score of ≥3.
The previous MS ABSST scoring algorithm was validated in a non-neurogenic female population. ABSST is a reliable, valid, and sensitive tool for screening women with UUI/OAB.
PMCID: PMC4234889  PMID: 24859795
Overactive bladder; Reliability; Sensitivity; Specificity; Urgency urinary incontinence; Validity
21.  Activity Restrictions after Gynecologic Surgery: Is There Evidence? 
Many surgeons recommend rest and restricting activities to their patients after surgery. The aim of this review is to summarize the literature regarding types of activities gynecologic surgeons restrict and intra-abdominal pressure during specific activities and to provide an overview of negative effects of sedentary behavior (rest).
We searched Pubmed and Scopus for years 1970 until present and excluded studies that described recovery of activities of daily living after surgery as well as those that assessed intra-abdominal pressure for other reasons such as abdominal compartment syndrome and hypertension. For our review of intra-abdominal pressure, we excluded studies that did not include a generally healthy population, or did not report maximal intra-abdominal pressures.
We identified no randomized trial or prospective cohort study that studied the association between post-operative activity and surgical success after pelvic floor repair. The ranges of intra-abdominal pressures during specific activities are large and such pressures during activities commonly restricted and not restricted after surgery overlap considerably. There is little concordance in mean peak intra-abdominal pressures across studies. Intra-abdominal pressure depends on many factors, but not least the manner in which it is measured and reported.
Given trends towards shorter hospital stays and off work intervals, which both predispose women to higher levels of physical activity, we urge research efforts towards understanding the role of physical activity on recurrence of pelvic organ prolapse and urinary incontinence after surgery.
PMCID: PMC3774134  PMID: 23340879
gynecologic surgery; physical activity; recovery; restrictions
22.  Joint hypermobility, obstetrical outcomes, and pelvic floor disorders 
Introduction and hypothesis
Benign joint hypermobility syndrome may be a risk factor for pelvic floor disorders. It is unknown whether hypermobility impacts the progress of childbirth, a known risk factor for pelvic floor disorders. Our objective was to investigate the association between joint hypermobility syndrome, obstetrical outcomes, and pelvic floor disorders. Our hypotheses were: (1) women with joint hypermobility are less likely to experience operative delivery and prolonged second-stage labor; and (2) pelvic floor disorders are associated with benign hypermobility syndrome, controlling for obstetrical history.
Joint hypermobility was measured in 587 parous women (participants in a longitudinal cohort study of pelvic floor disorders after childbirth). Their obstetrical histories were obtained from review of hospital records. Pelvic floor disorders were assessed using validated questionnaires and a structured examination for prolapse. Joint hypermobility and pelvic floor disorders were evaluated at enrollment (5–10 years after first delivery). We compared obstetrical outcomes and pelvic floor disorders between women with and without joint hypermobility, defined as a Beighton score ≥4.
Hypermobility was diagnosed in 46 women (7.8 %) and was associated with decreased odds of cesarean after complete cervical dilation or operative vaginal delivery [odds ratio (OR)=0.51; 95 % confidence interval (CI):0.27–0.95]. Anal sphincter laceration was unlikely to occur in women with hypermobility (OR=0.19; 95 % CI 0.04–0.80). However, hypermobility was not associated with any pelvic floor disorder considered.
Benign joint hypermobility syndrome may facilitate spontaneous vaginal birth but does not appear to be a risk factor for pelvic floor disorders in the first decade after childbirth.
PMCID: PMC3666322  PMID: 22898931
Benign joint hypermobility syndrome; Beighton criteria; Pelvic floor disorders; Pelvic organ prolapse
23.  Cardinal and deep uterosacral ligament lines of action: MRI based 3D technique development and preliminary findings in normal women 
Introduction and hypothesis
The cardinal ligament (CL) and deep uterosacral ligament (US) play a critical role in utero-vaginal support. This study aims to quantify their geometrical relationships in living women using a MRI-based 3D technique.
The angles between ligaments, the ligaments length and curvature were assessed on 3D models constructed from twenty MRIs of volunteers with normal support. How angle variation theoretically affects ligament tension was investigated using a simplified biomechanical model.
The CLs are 18.1 °±6.8 °(SD) from the cephalic-caudal body axis , and the USs are dorsally directed and 92.5 °±13.5 from the body axis. The CLs are longer and more curved than US. The theoretical calculated tension on CL is 52 % larger than that on US.
The CL is relatively parallel to the body axis while the US is dorsally directed. The tensions on these ligaments are affected by their orientations.
PMCID: PMC3986864  PMID: 22618207
Cardinal ligament; Uterosacral ligament; Pelvic organ prolapse; Apical support
24.  Spontaneous pushing to prevent postpartum urinary incontinence: a randomized, controlled trial 
Introduction and hypothesis
The risk for urinary incontinence can be 2.6-fold greater in women after pregnancy and childbirth compared with their never-pregnant counterparts, with the incidence increasing with parity. We tested the hypothesis that the incidence of de novo postpartum urinary incontinence in primiparous women is reduced with the use of spontaneous pushing alone or in combination with perineal massage compared with women who experienced traditional directed pushing for second-stage management.
This was a prospective clinical trial enrolling and randomizing 249 women into a four-group design: (1) routine care with coached or directed pushing, (2) spontaneous self-directed pushing, (3) prenatal perineal massage initiated in the third trimester, and (4) the combination of spontaneous pushing plus perineal massage. Self-report of incontinence was assessed using analysis of variance (ANOVA) and covariance (ANCOVA) models in 145 remaining women at 12 months postpartum using the Leakage Index, which is sensitive to minor leakage.
No statistical difference in the incidence of de novo postpartum incontinence was found based on method of pushing (spontaneous/directed) (P value=0.57) or in combination with prenatal perineal massage (P value=0.57). Fidelity to pushing treatment of type was assessed and between-groups crossover detected.
Spontaneous pushing did not reduce the incidence of postpartum incontinence experienced by women 1 year after their first birth due to high cross-over between randomization groups.
PMCID: PMC3980478  PMID: 22829349
Childbirth; Incontinence; Pelvic floor disorders; Pelvic floor muscle training; Perineal massage; Pregnancy; Second-stage management
Introduction and hypothesis
Acidic fruits are commonly cited in the lay press as potential bladder irritants that may promote urinary incontinence (UI), but no epidemiologic studies have examined this issue. We hypothesized that higher intake of acidic fruits might be related to greater risk of UI incidence and progression in women.
In one set of analyses, we included women without UI at study baseline in the Nurses’ Health Studies (NHS), with 34,144 women aged 54–79 in NHS I and 31,024 women aged 37–54 in NHS II. These cohorts were established among women living in the United States. Incident UI was ascertained over four years of follow up, and acidic fruit consumption was measured by food frequency questionnaire prior to UI onset. In a second set of analyses, we examined UI progression over two years of follow up among 11,764 women in NHS I and 11,299 women in NHS II with existing UI. Multivariable-adjusted relative risks were calculated for the associations of acidic fruit intake and UI incidence and progression.
We found no relation between acidic fruit intake and risk of developing UI, including urgency, mixed, and stress UI. In addition, there was no association between consumption of acidic fruits and UI progression, regardless of UI type.
No associations were detected between acidic fruit intake and UI in this large, prospective study of women. These data have implications for the development of evidence-based dietary guidelines around acidic fruits and UI, particularly because acidic fruits likely have many health benefits.
PMCID: PMC3558558  PMID: 22878474
aging; cohort studies; diet; epidemiology; urinary incontinence

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