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Female pelvic medicine & reconstructive surgery  2014;20(1):10.1097/SPV.0b013e3182a33194.
To describe a novel surgical technique for complete excision of a rectovaginal fistula tract using a disposable biopsy punch during a transvaginal rectovaginal fistula repair and present our initial surgical experience.
Description of four cases of simple rectovaginal fistulas and an innovative surgical technique for the complete excision of the fistula tract using a disposable biopsy punch.
Successful three, nine and twelve month follow up of four cases with simple rectovaginal fistulas after transvaginal rectovaginal fistula repair using a novel approach for complete fistula tract excision with a disposable biopsy punch and layered non overlapping suture closure. Demographic information reported included age, parity, medical and surgical history as well as fistula characteristics including size, location, presenting symptoms and duration of symptoms. We describe our operative technique with picture description.
This novel approach using a disposable punch biopsy device to complete excision of simple rectovaginal fistula tracts during a transvaginal rectovaginal fistula repair can help with achieving a successful surgical outcome.
PMCID: PMC3872741  PMID: 24368490
Rectovaginal fistula; fistula tract; transvaginal repair; biopsy punch
2.  Two-Year Outcomes After Vaginal Prolapse Reconstruction With Mesh Pelvic Floor Repair System 
The aim of this study was to assess anatomical and functional outcomes 2 years after prolapse repair using vaginal mesh repair system.
Women enrolled in a 12-month observational study of outcomes after transvaginal mesh-augmented prolapse repair were invited to participate in an extended follow-up. Subjects completed questionnaires assessing pelvic symptoms, quality of life, global satisfaction, and a pelvic examination for anatomical support and mesh complications.
Of 118 eligible women, 85 enrolled, 82 provided subjective data at 24 months, and pelvic examination/Pelvic Organ Prolapse Quantification data are available from 79 women. Total, anterior, and posterior Prolift kits were used in 47 (55%), 25 (29%), and 13 (15%), respectively. At baseline, most of the women had stage III prolapse (75%), with the anterior compartment constituting the leading edge in 71% of subjects. At 24 months, Pelvic Organ Prolapse Quantification measures were significantly improved from baseline in all compartments, with 51 (65%) stage 0/I, 25 (31%) stage II, 3 (4%) and stage III (P < 0.001), as were quality of life scores (P < 0.001), with the exception of sexual function. Symptomatic prolapse was reported by 7 (8.5%) women, of which 4 demonstrated prolapse in the nonoperated compartment. Three subjects (4%) reported persistent pelvic pain. The 2-year mesh exposure incidence was at least 13% (11/85). The proportion reporting dyspareunia was 28.9% (13/45) and was unchanged from baseline. The median global satisfaction was 9.3 (range 2.0–10.0).
Anatomical support, symptom relief, and satisfaction are high 24 months after mesh-augmented vaginal prolapse repair, although mesh exposure and new onset prolapse of the nonoperated compartment are not uncommon.
PMCID: PMC4261688  PMID: 23442503
vaginal mesh; pelvic organ prolapse; anatomical outcomes; functional outcomes
3.  Prolapse Symptoms in Overweight and Obese Women Before and After Weight Loss 
To estimate the association between BMI and pelvic organ prolapse symptoms and bother among overweight and obese women with urinary incontinence before and after weight loss.
Women (N=338) were randomized to either an intensive 6-month weight loss or educational program (control); they were evaluated for prolapse symptoms at baseline and 6 months. Symptomatic prolapse was defined as a positive response to at least one prolapse subscale question of the Urogenital Distress Inventory. “Bother” was defined as responses of slight, moderate or great. Women with prolapse symptoms were analyzed by baseline BMI category: overweight, obese and severely obese at baseline and at 6 months. Proportional odds regression and chi square tests for trend were used for analysis.
Mean +/−SD age was 53 ± 10 years, BMI was 36 ± 6 kg/m2, and 78% were white. A higher proportion of obese women reported feeling vaginal bulging compared to overweight women (13 % vs. 0 %, P=<.01). At baseline, 37% (N=124) reported bothersome “lower abdominal pressure”, 18% (N=62) bothersome “heaviness in the pelvic area”, and 14% (N=48) bothersome “pelvic discomfort when standing”. Nine percent (N=31) reported bothersome “feeling” and 2% (N=6) reported bothersome “seeing a bulge” in the vagina. At 6 months, there were no significant differences in improvement of self-reported bothersome prolapse symptoms in women in the weight loss or the control group.
In this study of overweight and obese women, increasing BMI was only associated with “feeling” a vaginal bulge. Weight loss did not improve bothersome prolapse symptoms.
PMCID: PMC4247226  PMID: 22453270
obesity; prolapse; symptoms
4.  Vaginal approach to vesicovaginal fistula and vaginal vault prolapse preserving sexual function by Latzko repair and sacrospinous suspension 
The combination of vesicovaginal fistula and complete vaginal vault prolapse is rare. The only published treatment recommendations concern partial colpocleisis; an option that precludes intercourse. In this case report, we describe successful repair of this problem with a Latzko fistula repair and concomitant Michigan four-wall sacrospinous ligament suspension: curing the fistula, correcting the prolapse and preserving sexual function.
PMCID: PMC4176931  PMID: 22983277
vesicovaginal fistula; pelvic organ prolapse; Latzko; sacrospinous ligament suspension
5.  Delayed Presentation of Pseudoabscess Secondary to Injection of Pyrolitic Carbon-Coated Beads Bulking Agent 
Periurethral masses after injection of Durasphere® bulking material have been previously reported to occur within 12-18 months of administration of the agent.
We present a case report of an anterior vaginal wall mass resulting from a pseudoabscess containing Durasphere® agent 5 years after injection. A literature review of urethral bulking agent complications and imaging is also provided.
The patient's anterior vaginal wall mass was thought to be due to a pseudoabscess secondary to injection of bulking agent. Pelvic imaging was helpful both in identifying the mass and in surgical planning. The patient was successfully treated by outpatient transvaginal resection of the material.
Urethral bulking agents, while generally safe and effective in the treatment of stress urinary incontinence, can lead to formation of pseudoabscesses. Although these are usually recognized within the first 18 months after injection, they may not be identified until several years later.
PMCID: PMC4164159  PMID: 22983276
Durasphere; Urethral Bulking Agent; Pelvic Imaging; Vaginal Wall Mass; Pseudoabscess
6.  Defining patient knowledge and perceptions of vaginal mesh surgery 
Given recent government investigations and media coverage of the controversy regarding mesh surgery, we sought to define patient knowledge and perceptions of vaginal mesh surgery.
Study Design
An anonymous survey was distributed to a convenience sample of new patients at Urogynecology and Female Urology clinics at a single medical center during April–June 2012. The survey assessed patient demographics, information sources, beliefs and concerns regarding mesh surgery. Fisher’s exact test was used to identify predictors of patients’ beliefs regarding mesh. Logistic and linear regressions were used to identify predictors of aversion to surgery and higher concern regarding future surgery.
164 women completed the survey; 62.2% (102/164) indicated knowledge of mesh surgery for prolapse and/or incontinence and were included in subsequent analyses. Mean age was 58.0±12.5 years and 24.5% reported prior mesh surgery. The most common information source was TV commercials (57.8%); only 23.5% of women reported receiving information from a medical professional. Participants indicated the following regarding vaginal mesh: class-action lawsuit in progress (55/102, 54.0%), causes pain (47/102, 47.1%), possibility of rejection (35/102, 34.3%), can cause bleeding and become exposed vaginally (30/102, 29.4%), and should be removed due to recall (28/102, 27.5%). Of these women, 22.1% (19/86) indicated they would not consider mesh surgery. On multivariable logistic regression, level of concern, information from friends/family, and knowledge of class-action lawsuit predicted aversion to mesh surgery.
Nearly two-thirds of new patients had knowledge of vaginal mesh surgery. We identified considerable misinformation and aversion to future mesh surgery among these women.
PMCID: PMC4102428  PMID: 23982577
Media; patient counseling; television commercials; vaginal mesh surgery
7.  Botulinum Toxin Type A (BOTOX) for Refractory Myofascial Pelvic Pain 
To assess intralevator Botulinum toxin type A (Botox) injections for refractory myofascial pelvic pain with short tight pelvic floor.
Retrospective cohort study of all women with intralevator Botox injection (100-300 Units) from 2005 through 2010 for refractory myofascial pelvic pain. Primary outcomes were self-reported pain on palpation and symptom improvement. Secondary outcomes included post-injection complications and repeat injection. Pain was assessed during digital palpation of the pelvic floor muscles using a scale of 0-10, with 10 being the worst possible pain. Follow-up occurred at <6 weeks post-injection and again at ≥ 6 weeks. Data are presented as median (interquartile range) or proportion.
Thirty-one patients met eligibility criteria; 2 were lost to follow up and excluded. Median age was 55.0 years (38.0-62.0). Before Botox injection, median pain score was 9.5 (8.0-10.0). Twenty-nine patients (93.5%) returned for the first follow-up visit; 79.3% reported improvement in pain, while 20.7% reported no improvement. Median pain with levator palpation was significantly lower than before injection (P<0.0001). Eighteen women (58.0%) had a second follow-up visit with a median pain score that remained lower than before injection (P<0.0001). Fifteen (51.7%) women elected to have repeat Botox injection; the median time to repeat injection was 4.0 (3.0-7.0) months. Three (10.3%) women developed de-novo urinary retention, 2 (6.9%) reported fecal incontinence and 3 (10.3%) reported constipation and/or rectal pain; all side effects resolved spontaneously.
Intralevator injection of Botox demonstrates effectiveness in women with refractory myofascial pelvic pain with few, self-limiting adverse effects.
PMCID: PMC3757523  PMID: 23982578
BOTOX; Myofascial pelvic pain; Short tight pelvic floor
8.  Stem Cell Homing Factor, CCL7, Expression in Mouse Models of Stress Urinary Incontinence 
Animal models of vaginal distention (VD) have demonstrated increased expression of chemokine (C-C motif) ligand 7 (CCL7). In this study, we investigated the expression of CCL7 in mice models of simulated birth trauma-induced urinary incontinence utilizing VD and pudendal nerve transection (PNT).
Forty-nine mice were divided into 6 groups: VD, sham VD, PNT, sham PNT anesthesia, and age-matched controls. The urethra, vagina, and rectum were harvested for the expression of CCL7 immediately or 24 hours after assigned procedure. Venous sampling for quantification of serum CCL7 was also performed. An ANOVA model was used to compare the relative expression of CCL7 in each group.
Urethral CCL7 expression in the VD group was significantly higher than control group after 24 hours (p<0.01). There was no difference in the urethral CCL7 expression in PNT, sham PNT, sham VD or anesthesia groups compared with controls. No statistically significant difference was noted in the vaginal and rectal expression of CCL7 between any of the groups except for sham PNT. Statistically significant differences were noted in the serum CCL7 expression in VD, PNT and sham PNT (p<0.01 in all) groups after 24 hours compared with the control group.
This study demonstrates over-expression of urethral CCL7 after VD but not PNT. This suggests that nerve injury does not contribute to the CCL7 over-expression. The over-expression of CCL7 in the serum of mice after VD suggests a translational potential where CCL7 measurement could be used as a surrogate for injury after delivery.
PMCID: PMC4116144  PMID: 24165450
CCL7; pudendal nerve transection; stem cells; vaginal distension
9.  Apical descent in the office and the operating room: the effect of prolapse size 
The support of the uterine cervix assessed in the clinic with Valsalva or cough and operating room (OR) with traction often differs. The objective of this study is to test the null hypothesis that the difference between preoperative and intraoperative values of POP-Q (Pelvic Organ Prolapse Quantification) point C is not related to prolapse size, and to determine if other factors exist that predict this difference.
This is a retrospective review of women who had a vaginal hysterectomy in the FPMRS (Female Pelvic Medicine and Reconstructive Surgery) division between 2005 and 2011 and had preoperative and intraoperative POP-Q point C recorded. A difference of 5 cm was established by a panel of urogynecologists as clinically significant. Student t-tests and chi-squared analyses were used and a logistic regression performed.
There were 206 subjects included. The mean difference in point C between the two clinical settings was 3.5 cm. A difference of ≥5 cm was present in 33%. The mean difference in point C was larger for women with lesser stages of prolapse (stage 1: 5.8 cm, stage 2: 3.0 cm, stage 3/4: 1.4 cm, p<.001). A difference of ≥5 cm in point C was more often present in women with lesser stages of prolapse–70.3% of women with stage 1, 9.3% for stage 2 and 8.5% for stage 3 (p<0.001).
We reject our null hypothesis. A difference of ≥5 cm between POP-Q point C in the clinic and the operating room occurred more frequently in women with lesser stages of prolapse.
PMCID: PMC4080625  PMID: 23982576
cervical traction; pelvic organ prolapse; prolapse staging
10.  Increased fluid intake is associated with bothersome bowel symptoms among women with urinary incontinence 
To determine the association between the type and volume of fluid intake and bowel symptoms in women with urinary incontinence. We hypothesize that a lower volume of fluid intake would be associated with greater straining with bowel movements in women with urinary incontinence.
We performed a cross sectional study of 256 women presenting with complaints of urinary incontinence from 2009 to 2010. Data on fluid intake, fluid intake behavior, urinary and bowel symptoms was collected using validated questionnaires. The relationship between quartiles of total daily fluid intake and bowel symptoms was analyzed.
The behavior of restricting fluid intake was reported by 32% women. Increasing quartiles of total daily fluid intake was significantly associated with greater bother from straining with bowel movements (p=0.04). Women with no bother from straining with bowel movements had significantly lower median daily fluid intake (2839 mL) than women with quite a bit of bother (3312 mL, p=0.01). The association between volume of fluid intake and straining with bowel movements persisted after controlling for age, body mass index, history of prolapse or incontinence surgery, and stage of prolapse (p <0.05). There was no association between caffeinated fluid intake and any bowel symptom or between the behavior of restricting fluid intake and any bowel symptom.
In women with urinary incontinence, higher volume of total fluid intake is reported by women with greater straining with bowel movements. The behavior of fluid restriction is not associated with bothersome bowel symptoms.
PMCID: PMC3635062  PMID: 23611933
fluid intake; bowel symptoms; urinary incontinence
11.  Racial Differences in Fecal Incontinence in Community-Dwelling Women from the EPI Study 
Despite its prevalence and associated distress, fecal incontinence is not well understood. There are limited data regarding associations between fecal incontinence and race. The goal of this study was to estimate the prevalence of fecal incontinence, and to secondarily identify demographic, lifestyle and medical factors associated with fecal incontinence, especially with regards to race.
This was a planned secondary analysis of a population-based cross-sectional telephone interview survey of 2812 black and white community-dwelling women living in southeastern Michigan. The primary outcome measured was the prevalence of self-reported fecal incontinence, defined as any loss of stool during the previous 12 months. Logistic regression modeling was used to identify characteristics independently associated with fecal incontinence.
16.7% of subjects reported fecal incontinence in the previous year. Fecal incontinence was approximately twice as common in white women (20%) as black women (11%). Factors associated with fecal incontinence differed between the two races, although its prevalence in both racial groups increases with higher numbers of medical comorbidities, increased frequency of bowel movements per week, and depression.
One in six women report fecal incontinence, although it occurs one-half as often in black as in white women. While there are common characteristics shared by women with fecal incontinence in both racial groups, white women experience fecal incontinence in complex with other pelvic floor disorders. For black women, fecal incontinence is an isolated pelvic floor disorder associated with mobility impairment.
PMCID: PMC4006939  PMID: 23611936
Fecal incontinence; Epidemiology; Pelvic floor dysfunction; Racial differences
12.  Communication Between Physicians And Spanish-Speaking Latin American Women With Pelvic Floor Disorders: A Cycle Of Misunderstanding? 
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.
PMCID: PMC3584345  PMID: 23442506
Pelvic Prolapse; Incontinence; Qualitative Methods; Health Literacy; Disease Understanding
13.  Obstetric Sphincter Injury Interacts with Diarrhea and Urgency to Increase the Risk of Fecal Incontinence in Women with IBS 
To confirm that fecal urgency and diarrhea are independent risk factors for fecal incontinence (FI), to identify obstetrical risk factors associated with FI in women with IBS (irritable bowel syndrome), and to determine whether obstetric anal sphincter injuries interact with diarrhea or urgency to explain the occurrence of FI.
The study is a supplement to a diary study of bowel symptoms in 164 female patients with IBS. Subjects completed daily bowel symptom diaries for 90 consecutive days and rated each bowel movement (BM) for stool consistency and presence of urgency, pain, and FI. All female participants from the parent study were invited to complete a telephone-administered 33-item bowel symptom and obstetric history questionnaire which included the Fecal Incontinence Severity Index (FISI).
Out of 164 women in the parent study, 115 (70.1%) completed the interview. Seventy-four (45.1%) reported FI on their diary including 34 (29.6%) who reported at least one episode per month, 112 (97.4%) reported episodes of urgency, and 106 (92.2%) reported episodes of diarrhea. The mean FISI score was 13.9±9.7. Upon multivariable analysis, FI was significantly associated with parity (p=0.007), operative vaginal delivery (p=0.049), obstetrical sphincter lacerations (p=0.007), fecal urgency (p=0.005), diarrhea (p=0.008), and hysterectomy (p=0.004), but was not associated with episiotomy, pelvic organ prolapse, or urinary incontinence. The synergistic interactions of obstetric anal sphincter laceration with urgency (p=0.002) and diarrhea (p=0.004) were significant risk factors for FI.
Fecal urgency and diarrhea are independent risk factors for FI, and they interact with obstetric anal sphincter laceration to amplify the risk of FI.
PMCID: PMC3920582  PMID: 23321658
fecal incontinence; obstetric anal sphincter injury; diarrhea; urgency
14.  Condition Specific Quality of Life 24 Months After Retropubic and Transobturator Sling Surgery for Stress Urinary Incontinence 
To compare quality of life (QoL) and factors associated with QoL change after retropubic (RMUS) and transobturator (TMUS) midurethral slings using the Incontinence Impact Questionnaire, (IIQ) and the International Consultation on Incontinence Questionnaire (ICIQ).
Five hundred ninety seven women in a multicenter randomized trial of RMUS vs. TMUS were examined. The IIQ and ICIQ were obtained at baseline, 12 and 24 months. Repeated measures analysis of variance tested for differences by treatment group over time. Multivariable analysis identified factors associated with QoL change at 12 months post- operative, controlling for treatment group and baseline QoL.
Improvement in IIQ was associated with: treatment success, younger age, improvement in stress incontinence (SUI) symptom severity and bother (all p < 0.05). Improvement in ICIQ was associated with treatment success, younger age, improvement in SUI symptom severity and bother, lower body mass index and no re-operation (all p < 0.05). Improvement of the IIQ was stable over time (p =0.35) for both treatment groups (p=0.66) whereas the ICIQ showed a small but clinically insignificant decline (p=0.03) in both treatment groups (p=0.51).
Postoperative QOL was improved after RMUS and TMUS. Measures of QOL functioned similarly, although more surgically modifiable urinary incontinence factors predicted improvement with the IIQ.
PMCID: PMC3902543  PMID: 22983273
Urinary incontinence; Quality of life; Midurethral sling
15.  Can women correctly contract their pelvic floor muscles without formal instruction? 
It is unknown how many women presenting for primary care can appropriately contract their pelvic floor muscle (PFM) or whether this ability differs between women with or without pelvic floor disorders. We sought to describe the proportion of women who initially incorrectly contract the PFM, and how many can learn after basic instruction.
This cross-sectional study enrolled 779 women presenting to community based primary care practices. During PFM assessment, research nurses recorded whether women could correctly contract their PFM after a brief verbal cue. We defined POP as prolapse to or beyond the hymen and SUI as a score of > 3 on the Incontinence Severity Index.
PFM contraction was done correctly on first attempt in 85.5%, 83.4%, 68.6%, and 85.8% of women with POP, SUI, both POP and SUI and neither POP nor SUI, respectively (p=0.01 for difference between POP and SUI versus neither POP nor SUI). Of 120 women who initially incorrectly contracted the PFM, 94 (78%) learned after brief instruction. Women with POP were less likely to learn than women with neither POP nor SUI (54.3% vs. 85.7%, p=0.001). Increasing vaginal delivery and decreasing caffeine intake (but not age or other demographic factors) were associated with incorrect PFM contraction; only decreased caffeine intake remained significant on multivariable analysis.
Most women with no or mild pelvic floor disorders can correctly contract their PFM after a simple verbal cue, suggesting that population-based prevention interventions can be initiated without clinical confirmation of correct PFM technique.
PMCID: PMC3551249  PMID: 23321652
Pelvic Organ Prolapse; Stress Urinary Incontinence; Pelvic Floor Muscles; kegel exercise
To examine the validity and reliability of a web-based version of the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ).
Participants included 876 women ages 38 to 65 attending primary care clinics in the Salt Lake Valley. Women completed a single web or paper based version of the symptom bother questions from EPIQ, and a subset repeated the same or opposite method at 2 separate time points. To assess subscales for the web-based version factor analysis of the 22 EPIQ items related to pelvic floor disorder (PFD) symptoms was performed using principal components analysis and varimax rotation. Internal consistency was assessed using coefficient alpha. Test-retest and inter-method reliability were assessed using intraclass correlation coefficients (ICC) for domain scores. Correlations above 0.70 were considered acceptable.
Overall, 384 and 492 women completed at least 1 web and 1 paper EPIQ and 93% were Caucasian with mean age of 50±7 years. Of these, 63 completed web-web, 57 web-paper, 47 paper-web and 109 paper-paper test-retest. Overall, factor analyses were consistent with the 7 domains of the original EPIQ. Cronbach’s alpha for the 4 symptomatic PFD domains and range of test-retest reliability for the various administration methods were similar to the original EPIQ instrument. Correlations for domain scores were above 0.70, except the anal incontinence scale (ICC=0.68.)
Web administration of the EPIQ has similar psychometric properties with comparable internal consistency and test-retest reliability when administered in the same modality. Reliability between both methods of administration is acceptable.
PMCID: PMC3774148  PMID: 23321654
Epidemiology; internet survey; pelvic floor disorders; questionnaire; web
17.  Communication Barriers among Spanish-speaking Women with Pelvic Floor Disorders: Lost in Translation? 
Female pelvic medicine & reconstructive surgery  2013;19(3):10.1097/SPV.0b013e318288ac1c.
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.
PMCID: PMC3826443  PMID: 23611934
pelvic prolapse; urinary incontinence; disease understanding; underserved Latinas
18.  Do symptoms of voiding dysfunction predict urinary retention? 
We assessed the relationship between symptoms of voiding dysfunction and elevated post void urinary residual (PVR).
Cross-sectional study of women presenting for initial evaluation from February through July 2011. Charts were reviewed for demographics, voiding dysfunction symptoms, and examination findings. Urinary retention was defined as PVR ≥100cc. Data are presented as median (interquartile range) or proportion; test characteristics are reported with 95% confidence intervals.
Of 641 eligible women, 57 (8.9%) had urinary retention. Of these, 32 (56.1%) had at least one symptom of voiding dysfunction, most commonly sensation of incomplete emptying (30.1%). Sensitivity and positive predictive values of voiding dysfunction symptoms were low. Of 254 women reporting voiding symptoms, most (87.5%) had PVR<100 and were significantly more likely to have other pelvic floor symptoms and findings.
Patient symptoms do not predict urinary retention. PVR should be measured and other causes of voiding dysfunction symptoms should be considered.
PMCID: PMC3512564  PMID: 23143428
Incomplete bladder emptying; Post void residual; Urinary retention; Voiding dysfunction
19.  Patient Understanding of Pelvic Floor Disorders: What Women Want to Know 
To assess the effect of initial visit with a specialist on disease understanding in women with pelvic floor disorders.
Women with referrals or chief complaints suggestive of urinary incontinence (UI) or pelvic organ prolapse (POP) were recruited from an academic urology clinic. Patients completed a Test of Functional Health Literacy in Adults (TOFHLA) and scripted interview sessions before and after the physician encounter. Physician treatment plans were standardized based on diagnosis and were explained using models. Interview transcripts were analyzed using qualitative grounded theory methodology.
Twenty women with pelvic floor disorders (UI or POP) were recruited and enrolled in this pilot study. The mean age was 60.5 years (range 31–87 years) and the majority of women were Caucasian with a college degree or beyond. TOFHLA scores indicated adequate to high levels of health literacy. Preliminary themes before and after the physician encounter were extracted from interviews, and two main concepts emerged: 1) After the initial physician visit, knowledge of their diagnosis and the ability to treat their symptoms relieved patient concerns related to misunderstandings of the severity of their disease 2) Patients tended to focus on treatment and had difficulty grasping certain diagnostic terms. This resulted in good understanding of treatment plans despite an inconsistent understanding of diagnosis.
Our findings demonstrated a significant effect of the initial physician visit on patient understanding of her pelvic floor disorder. Despite the variation in diagnostic recall after the physician encounter, patients had good understanding of treatment plans. This served to increase perceived control and adequately relieve patient fears.
PMCID: PMC3733672  PMID: 22543763
20.  Health Literacy and Disease Understanding among Aging Women with Pelvic Floor Disorders 
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.
PMCID: PMC3723393  PMID: 23143427
pelvic floor disorders; health literacy; incontinence; pelvic organ prolapse
21.  TVT-Secur (Hammock) Versus TVT-Obturator: A Randomized Trial of Suburethral Sling Operative Procedures 
This study aimed to compare TVT-Secur (TVT-S) and TVT-Obturator (TVT-O) suburethral slings for treatment of stress urinary incontinence (SUI).
This was a single-center, nonblinded, randomized trial of women with SUI who were randomized to TVT-S or TVT-O from May 2007 to April 2009. The primary outcome, SUI on cough stress test (CST), and quality-of-life and symptom questionnaires (Pelvic Floor Distress Inventory [PFDI-20] and Pelvic Floor Impact Questionnaire [PFIQ-7]) were assessed at 12 weeks and 1 year.
Forty-three women were randomized to TVT-S and 44 to TVT-O. There were no differences in median baseline PFDI-20 and PFIQ-7. Twenty-two (52.4%) of 42 participants randomized to TVT-S had a positive CST result at evaluation after 12 weeks or 1 year, whereas 4 (9.1%) of the 44 in the TVT-O group had a positive CST result. The intent-to-treat analysis showed that the risk of a positive CST result was 6 times higher after TVT-S than TVT-O (risk ratio, 6.0; 95% confidence interval [CI], 2.3–16.0). Among women not lost to follow-up, the risk ratio for a positive CST result after TVT-S compared with TVT-O was 17.9 (95% CI, 2.5–128.0) at 12 weeks and 3.5 (95% CI, 1.1–11.0) at 1 year. Both TVT-S and TVT-O resulted in improved quality of life and symptoms at 12 weeks. There was no difference between the groups for PFDI-20 (P = 0.40) or PFIQ-7 (P = 0.43). A similar pattern was seen at 1 year (P = 0.85 and P = 0.36).
The TVT-S seems to have a higher risk of positive postoperative CST result; however, the procedures result in similar improvements in quality of life and symptoms.
PMCID: PMC3712515  PMID: 22453267
TVT-Secur; TVT-Obturator; stress incontinence; efficacy
22.  Assessment of Women With Defecatory Dysfunction and Manual Splinting Using Dynamic Pelvic Floor Magnetic Resonance Imaging 
This study aimed to describe magnetic resonance imaging (MRI) findings in women with defecatory dysfunction who perform manual splinting.
This is a retrospective study of 29 patients from a single urogynecology center who presented with complaints of defecatory dysfunction and who reported manual splinting to assist with bowel movements. Patients were scheduled for an MRI study with a novel “splinting” protocol to evaluate the effects of their manual splinting on the pelvic floor. The protocol involved asking patients to splint during the MRI, as they normally would when trying to defecate. The goal was to evaluate any change in pelvic anatomy and compensation for an anatomic defect that could potentially lead to their defecatory dysfunction. Magnetic resonance images of the pelvis were obtained at rest, with pelvic floor contraction, with Valsalva, and during manual splinting. These images were then reviewed by radiologists who evaluated various parameters, including anorectal angle, levator ani muscle integrity, and the presence of rectocele, cystocele, apical prolapse, and enterocele. The external and internal anal sphincters were also evaluated for continuity.
From September 2008 to October 2010, 29 women reported defecatory dysfunction and the need for manual splinting. Their mean (SD) age was 55.2 (10.5) years. Magnetic resonance images showed a rectocele in 86.2% of the study group, cystocele in 75.9%, enterocele in 10.3%, and a defect of the levator ani muscles in 17.2%. Twentyone (72.4%) women had more than 1 of these defects. In addition, 27.6% had an anorectal angle less than 90 degrees or greater than 105 degrees.
Patients in the study group splinted in the vagina (58.6%), on the perineum (31.0%), or on the buttock (10.3%). In all but 1 woman (96.6%), splinting improved or completely corrected the identified defect(s) as evidenced with MRI. Among those who used vaginal splinting, 52.9% of defects were corrected and 47.1% were improved. Perineal splinting corrected 55.6% and improved 33.3% of cases and was ineffective in 11.1% of cases, whereas buttock splinting corrected 33.3% and improved 66.7% of cases.
Most women in our study group who used manual splinting to assist in defecation are compensating for a pelvic floor defect that can be detected on MRI. Magnetic resonance imaging of the pelvis may help elucidate the etiology of the defecatory dysfunction in some women and may assist pelvic reconstructive surgeons in planning surgical correction of pelvic floor defects. Magnetic resonance imaging may also identify defects in the pelvic floor that are, at the present time, not amenable to surgical correction.
PMCID: PMC3707403  PMID: 22453259
splinting; defecatory dysfunction; MRI; pelvic organ prolapse; pelvic floor; constipation; dynamic MRI; obstructed defecation; rectocele; cystocele; enterocele; apical vaginal prolapse; vaginal vault prolapse
23.  Longitudinal Changes in Pelvic Organ Support Among Parous Women 
The objective of this study was to characterize changes in pelvic organ support and symptoms of prolapse over time and identify characteristics associated with worsening of support.
Participants were recruited based on the mode of delivery (cesarean vs vaginal delivery) of their first child. The Pelvic Organ Prolapse Quantification system was used to describe support at baseline and 12 to 18 months later. Symptoms were assessed using a validated questionnaire. Outcomes of interest included the proportion of women with a change in support greater than 1 cm at the anterior vaginal wall (Ba) or posterior vaginal wall (Bp) and a change in support greater than 2 cm at the apex (C). Characteristics associated with worsening of support were identified using 2-sided Fisher’s exact test and multivariable logistic regression.
Among 749 participants, 60% had delivered by cesarean delivery only. Worsening support at Ba, Bp, and C was observed in 8%, 2%, and 6%, respectively. Worsening at any point was observed in 110 women (15%). Women with prolapse symptoms at baseline were not more likely to experience worsening of support. In a multivariable model, age older than 40 years (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.09–2.49), vaginal delivery (OR, 3.12; 95% CI, 1.38–7.07), and genital hiatus greater than or equal to 2 (OR, 2.36; 95% CI, 1.03–5.43) were all associated with worsening support in at least 1 compartment.
Over 12 to 18 months, characteristics most strongly associated with worsening of pelvic support include genital hiatus size, vaginal birth, and age.
PMCID: PMC3657298  PMID: 22777372
pelvic organ prolapse; child birth; vaginal delivery; natural history; longitudinal study
24.  Validation of the Activities Assessment Scale in Women undergoing Pelvic Reconstructive Surgery 
The Activities Assessment Scale (AAS) is a 13-item postoperative functional activity scale validated in men undergoing hernia surgery. We evaluated the psychometric characteristics of the AAS in women undergoing vaginal surgery for prolapse (POP) and stress incontinence (SUI).
Participants included 163 women with POP and SUI enrolled in a randomized trial comparing sacrospinous ligament fixation to uterosacral vault suspension with and without perioperative pelvic floor muscle training. Participants completed the AAS and SF-36 at baseline and 2-weeks and 6-months post-operatively. Internal reliability of the AAS was evaluated using Cronbach’s alpha. Construct validity and responsiveness were examined in cross-sectional and longitudinal data using Pearson’s correlation coefficient and ANOVA. The AAS is scored from 0–100 (higher scores = better function).
Mean baseline AAS score was 87± 17.3 (range 25 to 100). Functional activity declined from baseline to 2-weeks post-operatively (mean change −4.5; 95% CI −7.6 to −1.42) but improved above baseline at 6-months (mean change +10.9; 95% CI 7.8 to 14.0). Internal reliability of the AAS was excellent (Cronbach’s Alpha = 0.93). Construct validity was demonstrated by a correlation of 0.59–0.60 between the AAS and SF-36 Physical Functioning Scale (p<0.0001) and lower correlations between the AAS and other SF-36 scales. Patients who improved in physical functioning based on the SF-36 between 2-weeks and 6-months postoperatively showed an effect size of 0.86 for change in the AAS over the same time period.
The AAS is a valid, reliable and responsive measure for evaluation of physical function in women after pelvic reconstructive surgery.
PMCID: PMC3666046  PMID: 22777368
Functional Activity; Postoperative Activity; Scales; Pelvic Reconstructive Surgery; Pelvic Organ Prolapse
25.  Validation of the Surgical Pain Scales in Women undergoing Pelvic Reconstructive Surgery 
Surgical Pain Scales (SPS) consist of 4 items that measure pain at rest, during normal activities, during work/exercise and quantify unpleasantness of worst pain, which are valid and responsive in men undergoing hernia repair. Our objective was to evaluate the psychometric properties of SPS in women undergoing vaginal surgery for pelvic organ prolapse (POP) and stress urinary incontinence (SUI).
We modified SPS by converting original response scales from a visual analog scale (VAS) to Numerical Rating Scales (NRS). NRS have lower error rates and higher validity than VAS. The sample included 169 women with stage II–IV POP and SUI in a randomized trial comparing sacrospinous ligament fixation to uterosacral vault suspension with and without pelvic floor muscle training. Participants completed SPS and SF-36 at baseline, 2-weeks and 6-months after surgery. Construct validity and responsiveness were examined in cross-sectional and longitudinal data using Pearson’s correlation and ANOVA.
Pain at rest, during normal activities and during work/exercise worsened at 2-weeks (p<0.05) and all measures of pain improved from baseline to 6 months (p<0.0001). Construct validity was demonstrated by correlations of .51–.74 between SPS and the SF-36 Bodily Pain Scale (p<0.0001). Pain worsened on SF-36 between baseline and 2-weeks in 63% of participants and this group demonstrated a mean increase in pain of 1.9 (SD 2.8) on the SPS (effect size 0.99) confirming responsiveness of the scale.
The modified Surgical Pain Scales are valid and responsive in women after pelvic reconstructive surgery.
PMCID: PMC3677159  PMID: 22777367
Postoperative Pain; Scales; Pelvic Reconstructive Surgery; Pelvic Organ Prolapse

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