Retrospective Study of Long-term Surgical Outcomes in Patients Who had a Vaginal Hysterectomy in Conjunction with Pelvic Organ Prolapse Surgery.

INTRODUCTION: Data on long-term outcomes and subjective patient symptom improvement following primary native tissue pelvic organ prolapse repair is limited. Our primary aim was to evaluate the long-term prolapse recurrence and retreatment rates of women who have undergone native tissue prolapse repair. Our secondary aim was to evaluate subjective patient improvement in pelvic floor symptoms and quality of life 7 to 10 years after surgery. METHODS: This retrospective cohort study included patients who had undergone primary prolapse repair surgery including a hysterectomy and native tissue repair by a single surgeon at a tertiary pelvic floor center from 2009 to 2013. The Pelvic Floor Distress Inventory was distributed to subjects before and 7 to 10 years after surgery and preand post-operative survey results were compared. Subjects were asked if they had symptom recurrence and if they required retreatment. RESULTS: One hundred twelve of the 204 distributed surveys were returned, yielding a 54.9% response rate. 8.6% of subjects reported prolapse symptom recurrence. 1.9% of subjects were retreated with a pessary. No subjects required additional prolapse repair surgery. 77.1% of subjects had improved PFDI-20 scores following surgery with an average improvement of 46.21 points. Statistically significant score improvements were also observed on PFDI-20 subsections. CONCLUSIONS: Primary pelvic organ prolapse repair utilizing native tissue results in low recurrence and retreatment rates. Patients can expect long-term clinical improvement in pelvic floor disorders and quality of life following prolapse surgery. Definitions of surgical success should be based on subjective patient symptoms and quality of life measures.

Why South Dakota is Ready for a Perineal Clinic: A Research-Based Proposal and Review.

Perineal trauma is a significant complication of childbirth that can drastically influence an individual's quality of life. Pain, infection, fecal incontinence, and many other adverse outcomes can impact and endanger a woman's life following perineal injury. Early identification, referral and multi-disciplinary care are vital in the correct management of these injuries. The purpose of this manuscript is to discuss the prevalence and etiology of perineal trauma, explain the management of perineal injury and to highlight the important role a perineal clinic would play in South Dakota, especially rural areas, which could improve pelvic floor function and quality of life for these women.

Training of Physical Therapists in Pelvic Floor Techniques: Is Care Available in the Rural Midwest?

INTRODUCTION: The number of patients affected by pelvic floor disfunction is predicted to continue to grow in the future. Pelvic floor physical therapy (PFPT) is a benign, first-line treatment for a variety of pelvic disorders. There is currently a failure rate estimated at 19.8 percent for this conservative therapy. The present study aims to investigate if the high failure rate of conservative treatment is due to a lack of training and availability of therapists in the rural health care setting. METHODS: An anonymous survey was distributed to 53 physical therapists who practice within a targeted rural healthcare setting. Questions were designed to determine training received in graduate and post-graduate courses in PFPT while gauging level of involvement of PFPT within their practice. Proportions were calculated and then analyzed independently for standard deviation, standard error, and 80 percent confidence intervals. RESULTS: This project had a 45 percent response rate. 58 percent of these therapists received less than 2 hours of didactics in PFPT, and only 29 percent of the participants had a lab included in their graduate school curriculum. 95 percent of the participants attended additional post-graduate training in PFPT. The average number of courses attended was 3.33. Participants who stated that their training included hands-on training in female and/or male external and internal physical exam was 91.6 percent. CONCLUSION: This study identified only 53 providers in this rural healthcare region who are not receiving adequate training in PFPT during graduate school. Therapists have to seek post-graduate courses in order to be prepared to provide these services to patients.

Testing Clinical Skills: A Look at the OSCE and USMLE Clinical Skills Exams.

The Objective Structured Clinical Examination (OSCE) was introduced in the mid-1970s as a method of testing students' clinical skills with more objectivity. The University of South Dakota Sanford School of Medicine (USD SSOM) administered its first OSCE to third year students in 1996. At a national level, the U.S. Medical Licensing Examination (USMLE) incorporated clinical skills testing for all medical students in the form of Step 2 Clinical Skills (CS) in 2004. The USMLE Step 2 CS exam has both proponents and opponents, but at this time will continue to be used. The USD SSOM OSCE has evolved over the years to include standardized patients, simulations, and note writing in an effort to better assess students and prepare them for Step 2 CS. Currently, the USD SSOM OSCE administered at the end of Pillar 2 is a requirement for graduation. The formal OSCE committee works diligently throughout the year to provide students with ample opportunity to prepare them for success. A significant ongoing part of student preparation is the clinical training that they receive in the offices of dedicated community preceptors.

A Primer for the Primary Care Physician: Management of Overactive Bladder Syndrome.

Overactive bladder syndrome affects millions of women in the U.S. and is defined by urinary urgency, urinary frequency, and small volume voids, with or without nocturia and incontinence. Overactive bladder is a diagnosis of exclusion, and several therapies exist for the management of this condition. This article outlines a systematic approach that the primary care physician can take when treating a patient with overactive bladder.

Developing an Advanced Alternative Payment Model for Stress Urinary Incontinence.

ABSTRACT: Historically, our health care system has been based on a fee-for-service model, which has resulted in high-cost and fragmented care. The Center for Medicare & Medicaid Services is moving toward a paradigm in which health care providers are incentivized to provide cost-effective, coordinated, value-based care in an effort to control costs and ensure high-quality care for all patients. In 2015, the Medicare Access and Children's Health Insurance Program Reauthorization Act repealed the Sustainable Growth Rate and the fee-for-service model, replacing them with a 2-track system: Merit-based Incentive Payment System and the advanced Alternative Payment Model (aAPM) system. In 2016, the American Urogynecologic Society Payment Reform Committee was created and tasked with developing aAPMs for pelvic floor disorders. The purpose of this article is to describe the stress urinary incontinence aAPM framework, the data selected and associated data plan, and some of the challenges considered and encountered during the aAPM development.

Blastocyst embryo transfer is the primary determinant for improved outcomes in oocyte donation cycles.

AIM: Using oocyte donation cycles as an ideal model, we sought to compare pregnancy and implantation rates in cleavage stage (day 3) versus blastocyst stage (day 6) embryo transfers (ET); assess the predictive value of blastocyst formation rates based on cleavage cell stage and morphology grade; and evaluate the ability to predict formation of high quality (HQ) blastocysts. METHODS: Ninety three consecutive oocyte donation cycles from July 2003 to August 2005 were retrospectively evaluated and analyzed to determine if either resulted in a cleavage stage (n = 30) or blastocyst (n = 45) ET. The primary outcomes measured pregnancy rates, the percent development of HQ blastocysts based on day 3 embryo status, and the ability to select day 3 embryos suitable for transfer among four blinded evaluators by assessing their day 6 embryo outcome. RESULTS: Cleavage stage ET resulted in significantly lower pregnancy rates, clinical pregnancy rates, and implantation rates (47% [n = 14/30]; 40% [n = 12/30] and 27 + or - 7%) compared to blastocyst stage (82% [n = 37/45]; 73% [n = 33/45] and 64 + or - 6% [+ or -SE], P < 0.01). In total, HQ blastocysts resulted from high and good quality day 3 embryos 35% (191/546) and 17% (93/546), respectively. Blinded evaluation revealed at least one, two or all three day 3 embryos were correctly selected for ET on day 6, 97%, 67% and 19%, respectively. CONCLUSION: Day 6 ET resulted in significantly better clinical outcomes compared to day 3 ET. While day 3 status is not predictive of blastocyst quality, the selection of at least one day 3 embryo ultimately suitable for blastocyst ET underscores the significance of optimal endometrial receptivity.

Follicular and luteal phase endometrial thickness and echogenic pattern and pregnancy outcome in oocyte donation cycles.

PURPOSE: To study the effect of endometrial thickness (ET) and echogenic pattern (EP) in oocyte donation cycles upon pregnancy outcomes. METHODS: Seventy-nine cycles resulting in blastocyst embryo transfer were evaluated. Donors underwent ovarian hyperstimulation using rFSH and GnRH-antagonist. Recipients were synchronized to donors using GnRH-agonist down-regulation followed by fixed dose of estrogen (E2) and progesterone (P4) following hCG. Transvaginal ultrasound (US) obtained ET and EP 10-11 days after initiation of E2 and on day of embryo transfer. Primary outcome was ET and EP in pregnant and non-pregnant cycles. Stimulation and embryology data was analyzed in donors to assess differences prior to transfer. RESULTS: Fifty-nine cycles resulted in clinical pregnancy. No differences were observed in pregnant vs. non-pregnant cycles in proliferative or secretory ET and EP. Similar baseline and stimulation characteristics were found in pregnant and non-pregnant cycles. Regression analysis showed end thickness were not predictive of pregnancy outcomes. CONCLUSIONS: Endometrial characteristics in recipients prior to and following progesterone were not predictive of pregnancy outcomes.

Effect of Electronic Video Education on Patient's Self-Assessed Knowledge About Obesity and Pelvic Floor Disorders: A Randomized Controlled Trial.

OBJECTIVE: The objective of this study was to study the effect of electronic video education on patient's self-assessed perception of knowledge about pelvic floor disorders in relation to obesity in a prospective randomized controlled trial. METHODS: From June to July 2015, women with a body mass index of 25 kg/m or higher seeking care at a single urogynecology center were recruited and randomized into either a standard visit with an 8-minute video (group A) or a standard visit control (group B). Randomization was performed with computer-generated number blocks of 4. Allocation sequence was concealed from the caregiver, in sequentially numbered, opaque, and sealed envelopes. Immediately after their visit, patients answered a series of 3 questionnaires, which were statistically analyzed using unpaired t tests, Wilcoxon rank sum and analysis of variance tests, presented as mean and standard deviation. Primary outcome was a difference in self-assessed perception of knowledge questionnaire scores. Secondary outcome was a difference in motivation to lose weight. RESULTS: Forty-eight women enrolled, and 40 completed all questionnaires, 20 in each group. Representation in both groups was demographically similar. The mean (SD) answers for the postvisit survey measuring participant's self-assessed perception of knowledge was 3.9 (0.8) for group A and 3.5 (1.1) for group B (P = 0.002). Ninety percent of women in group A reported motivation to lose weight, compared with 75% in group B (P = 0.4). CONCLUSIONS: Participants who received electronic video education scored significantly higher on self-assessed perception of knowledge questionnaire about pelvic floor disorders in relation to obesity. The video did not increase motivation to lose weight.

Current Issues with Hysterectomy.

Hysterectomy is one of the most common gynecologic surgeries. Early adoption of surgical advancements in hysterectomies has raised concerns over safety, quality, and costs. The risk of potential leiomyosarcoma in women undergoing minimally invasive hysterectomy led the US Food and Drug Administration to discourage the use of electronic power morcellator. Minimally invasive hysterectomies have increased substantially despite lack of data supporting its use over other forms of hysterectomy and increased costs. Health care reform is incentivizing providers to improve quality, improve safety, and decrease costs through standardized outcomes and process measures.

Effective treatment of dyssynergic defecation using sacral neuromodulation in a patient with cerebral palsy.

BACKGROUND: Dyssynergic defecation is a complex bowel problem that leads to chronic constipation and abdominal pain. Management is often challenging owing to the incoordination of multiple pelvic floor muscles involved in normal defecation. CASE: We report a case of dyssynergic defecatory dysfunction in a patient with cerebral palsy treated with sacral neuromodulation. At presentation, Sitz marker study and magnetic resonance defecography showed evidence of chronic functional constipation. Anorectal manometry, rectal anal inhibitory reflex, and rectal sensation study showed intact reflex and decreased first sensation of lower canal at 50 mL. After stage 2 of InterStim implant placement, bowel habits improved to once- to twice-daily soft solid bowel movements from no regular solid bowel movements. Fecal incontinence improved from daily liquid and small solid loss to no stool leakage. CONCLUSIONS: In patients with systemic medical problems contributing to defecatory dysfunction and bowel incontinence, such as cerebral palsy, sacral neuromodulation was found to provide significant relief of bowel symptoms in addition to associated abdominal pain. As a result of intervention, the patient reported significant improvement in quality of life and less limitations due to dyssynergic defecation.

Passive biomechanical properties of human cadaveric levator ani muscle at low strains.

The objective of this study was to measure and model the passive biomechanics of cadaveric levator ani muscle in the fiber direction at low strains with a moderately slow deformation rate. Nine levator ani samples, extracted from female cadavers aged 64 to 96 years, underwent preconditioning and uniaxial biomechanical analysis on a tensile testing apparatus after the original width, thickness, and length were measured. The load extension data and measured dimensions were used to calculate stress-strain curves for each sample. The resulting stress-strain curves up to 10% strain were fit to four different constitutive models to determine which model was most appropriate for the data. A power-law model with two parameters was found to fit the data most accurately. Constitutive parameters did not correlate significantly with age in this study; this may be because all of the cadavers were postmenopausal.

Primary genitourinary melanoma presenting as voiding dysfunction.

A case of primary malignant melanoma of the urethra in a 67-year-old female is presented. Cystourethroscopy performed during a workup for pelvic organ prolapse revealed a bladder and urethral mass. Initial histologic examination was interpreted as undifferentiated sarcoma; however, after immunohistochemical staining by two separate institutions, malignant melanoma was diagnosed. Being rare, urethral melanoma is often misdiagnosed, and treatment can be delayed. Given its poor prognosis, early diagnosis is essential, and clinicians need to include it in their differential when working up a patient with genitourinary complaint.

Overcoming the challenging cervix: techniques to access the uterine cavity.

OBJECTIVE: To identify cervical stenosis and review medical, surgical, and radiological modalities to access the uterine cavity. MATERIALS AND METHODS: Computerized searches of Medline and PubMed from 1996 to 2005 were conducted using the key words "cervix," "cervical ripening," and "cervical stenosis." References from identified publications were manually searched and cross-referenced to identify additional relevant articles. We review relevant techniques on how to access the uterine cavity when cervical stenosis is encountered. RESULTS: Many gynecologic procedures require uncomplicated access through the cervix to access the uterine cavity, including hysteroscopy, dilation and curettage, sonohysterogram, hysterosalpingogram, endometrial biopsy, and embryo transfer for in vitro fertilization. These procedures can be quite complicated when a cervix is obstructed. Management techniques described include the medical use of misoprostol and laminaria, intraoperative ultrasound guidance, and operative creation of a new passage. Additionally, techniques for bypassing the obstructed cervix and preventing cervical stenosis have been described. CONCLUSIONS: Cervical stenosis can result in iatrogenic complications. Preoperative identification, cervical ripening agents, osmotic dilators, and the use of ultrasound guidance are useful in overcoming cervical stenosis. It is also key to identify those at risk for cervical stenosis and implement preventative techniques as needed.