A comparison of MRI-based pelvic floor support measures between young and old women with prolapse.

INTRODUCTION AND HYPOTHESIS: We sought to 1) test the hypothesis that young women (≤45 years) with pelvic organ prolapse have a higher prevalence of major levator ani muscle (LAM) defects than old women (≥70 years) with prolapse and 2) compare level II/III measurements between young and old women with prolapse and age-matched controls to evaluate age-related mechanistic differences in the disease process. METHODS: A secondary analysis examined four groups of parous women: young prolapse (YPOP, n = 17); old prolapse (OPOP, n = 17); young controls (YC, n = 15); old controls, (OC, n = 13). Prolapse was defined as any compartment at or beyond the hymen with vaginal bulge symptoms. Genital hiatus (GH) was measured on clinical exam. Major LAM defects and level II/III measurements (UGH: urogenital hiatus, LA: levator area, and apex location) were assessed on MRI at rest and strain, and the difference (Δ) between measurements calculated. Principal component analysis was used to evaluate levator plate (LP) shape. RESULTS: Major LAM defects occurred in 42% of YPOP and 47% of OPOP (p > .99). GHrest was 1.5 cm larger in OPOP versus YPOP (p < .001) and 2 cm larger in OPOP versus OC (p < .001). Regardless of prolapse status, LArest and UGHrest on MRI increased with age. YPOP had larger ΔLA (p = .04), ΔUGH (p = .03), and Δapex than OPOP (p = .01). Resting LP shape was more dorsally oriented in OPOP versus YPOP (p = .02) and OC versus YC (p = .004). CONCLUSIONS: Prolapse in young women cannot be solely explained by a higher LAM defect prevalence. GH size and other measures of level II/III pelvic support worsen with age regardless of prolapse status.

Reduction in Rates of Symptomatic Urinary Tract Infection After Pelvic Reconstructive Surgery: A Quality Improvement Analysis.

IMPORTANCE: Urinary tract infections contribute to high health care costs. OBJECTIVE: This study aimed to determine if a combination of interventions was successful at reducing the rate of postoperative symptomatic urinary tract infections (SUTIs) in a female pelvic medicine and reconstructive surgery (FPMRS) practice. STUDY DESIGN: Observational, retrospective quality improvement analysis looking at the rate of postoperative SUTI within 30 days of surgery in women who underwent gynecologic surgery performed by an FPMRS surgeon from October 2015 to October 2019. Symptomatic urinary tract infection was defined by symptoms and urinalysis, positive urine culture, or treatment for cystitis or urethritis within 30 days of surgery. Interventions were implemented between 2015 and 2016: perioperative cranberry use, intraoperative protocols for catheterization, and postoperative protocols for urinary retention management. In 2018, we added metronidazole to cefazolin for antibiotic prophylaxis. We developed a multivariable logistic regression to determine if postoperative SUTI rates decreased over the study period with adjustment for clustering by surgeons, patient factors, and surgery type. RESULTS: Of 2,389 procedures performed, 284 (11.8%) involved patients who had an SUTI within 30 days of surgery. The annual infection rate decreased 50% (year 1, 14.7%; year 4, 7.3%). Adjusting for age, race, body mass index, length of stay, surgery type, and surgeon, the odds of SUTI decreased 19% each year (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.72-0.91; P < 0.001). Compared with women who had other gynecologic procedures, those who underwent vaginal prolapse surgery with or without incontinence procedures (OR, 2.75; 95% CI, 1.35-5.54; P = 0.01) or incontinence surgery alone (OR, 2.65; 95% CI, 1.25-5.62; P = 0.01) were more likely to have an SUTI. CONCLUSION: Combining interventions can be highly effective in reducing postoperative SUTI rates.

Structural failure sites in posterior vaginal wall prolapse: stress 3D MRI-based analysis.

INTRODUCTION AND HYPOTHESIS: The objective was to identify structural failure sites in rectocele by comparing women with and those without posterior vaginal wall prolapse and accessing their relative contribution to rectocele size based on stress MRI-based measurements. METHODS: We studied three-dimensional stress MRI at maximal Valsalva of 25 women with (cases) and 25 without (controls) posterior vaginal prolapse of similar age and parity. Vaginal wall factors (posterior wall length and width); attachment factors (paravaginal posterior wall location, posterior fornix height, and perineal height); and hiatal factors (hiatal size and levator ani defects) were measured using Slicer 4.3.0® and a custom Python program. Stepwise linear regression was used to assess the relative contribution of all factors to the posterior prolapse size. RESULTS: We identified three primary factors with large effect sizes of 2 or greater: two attachment factors-posterior paravaginal descent and perineal height; and one hiatal factor-genital hiatus size. These were the strongest predictors of the presence and size of rectocele, the most common failure sites, found in 60-76% of cases; and highly correlated with one another (r = 0.72-0.84, p < .001). Longer vaginal length, wider distal vagina, lower posterior fornix, and larger levator ani hiatus had smaller effect sizes and were less likely to fall outside the norm (20-24%) than the three primary factors. When considering all the supporting factors, the combination of perineal height, posterior fornix height, and vaginal length explained 73% of the variation in rectocele size. CONCLUSIONS: Lower perineal and lateral posterior vaginal location and enlarged genital hiatus size were strong predictors of rectocele occurrence and size and correlated highly.

Musculoskeletal findings on MRI among postpartum women with persistent pelvic pain.

INTRODUCTION AND HYPOTHESIS: Persistent postpartum pelvic pain affects one in six women, and its source is often unexplained in the absence of obvious clinical findings. Musculoskeletal injuries during childbirth are common and can be detected using MRI or US; however, pelvic imaging is not standard of care in evaluating women with persistent pain. We hypothesize that clinical symptoms in women with unexplained persistent postpartum pelvic pain will correlate with musculoskeletal abnormalities identified on MRI in > 50% of cases. METHODS: Retrospective cohort study of women with persistent postpartum pelvic pain who underwent a pelvic MRI for this indication. Chart review was performed. MRI findings were classified as major (bone fracture, levator ani avulsion) or minor (edema, inflammation or partial levator ani defect). Descriptive statistics were used to describe the study population. RESULTS: Of the 252 women seen for postpartum pelvic pain, 18 patients met our study criteria. Half of women were primiparous (55.6%, n = 10). Operative delivery occurred in 27.8% (n = 5), 22.2% (n = 4) had anal sphincter lacerations, and 38.9% (n = 7) had prolonged second stage of labor. Median time from delivery to MRI was 4.5 ± 5.13 (IQR) months. Musculoskeletal abnormalities were found in 94.4% (n = 17) of cases; 38.8% (n = 7) were major and 55.6% (n = 10) were minor abnormalities. All findings correlated with presenting symptoms. CONCLUSION: Of women with persistent postpartum pelvic pain, 94.4% had musculoskeletal abnormalities supporting their clinical symptoms. Pelvic floor imaging should be considered in women with unexplained persistent postpartum pelvic pain to accurately manage the source of their pain.

Predictors of goal achievement in patients undergoing hysterectomy.

OBJECTIVE: The primary objective of our study was to identify predictors of goal achievement in patients undergoing simple hysterectomy for benign indications. We also sought to describe the goals of patients in this population. STUDY DESIGN: This was a prospective cohort study of patients undergoing hysterectomy for benign indications performed at a single academic institution. We documented patient-reported goals of treatment prior to undergoing hysterectomy in 57 patients, and assessed goal achievement and other patient-centered outcomes three months after surgery in 47 of the patients (82.5%). We compared patients who met all of their goals to those who did not, and used multivariate regression to identify predictors of goal achievement. We also characterized the general profile of goals for patients undergoing hysterectomy. RESULTS: We identified the primary surgical diagnosis of abnormal uterine bleeding (OR 6.5, 1.7-30.1, p = 0.006), as well as an increased feeling of being prepared for postoperative discharge (OR 11.9, 2.1-104.4, p = 0.005), to be independent predictors of patient goal achievement. Goal achievement was correlated with other patient-centered outcomes, including a higher sense of satisfaction and greater patient global impression of improvement. Goals related to symptoms were more commonly stated and more commonly achieved than functional goals. CONCLUSION: Goal achievement in patients undergoing hysterectomy depends on the preoperative diagnosis and the patient's feeling of preparedness for postoperative discharge. Goal achievement should be considered as a useful patient-centered outcome. Patients undergoing hysterectomy have a unique profile of goals which should be considered and addressed in preoperative counseling.