Variability in practice patterns in stress urinary incontinence and pelvic organ prolapse: results of an IUGA survey.

INTRODUCTION AND HYPOTHESIS: Members of the International Urogynecological Association (IUGA) come from different geographic locations and practice settings. A member survey regarding practice patterns provides valuable information for practitioners and researchers alike, and allows the IUGA to discover areas to focus on education and information dissemination. METHODS: A questionnaire was developed by the IUGA Research and Development committee and distributed electronically to IUGA surgeons. Answers were analyzed in reference to demographics, geographic distribution, and academic affiliation. RESULTS: Five hundred sixty-four members answered the questionnaire, representing a 28 % response rate, and closely reflecting the geographic distribution of IUGA membership. Preferred surgical treatment for uncomplicated SUI was the mid-urethral trans-obturator sling (49.7 %). Vaginal mesh was mainly used for repair of recurrent POP (20.4 %). Pessary use was offered "always" or "frequently" by 61.5 %, with no difference in academic affiliation, but significant differences based on region of practice. Compared to practitioners in non-academic centers, those with academic affiliation utilized Urodynamic studies (UDS) and Magnetic Resonance Imaging (MRI) more frequently in the evaluation of POP. Regions of practice significantly influenced the majority of practice patterns, with the highest impact found in the use of robotic assistance. CONCLUSIONS: Many practice patterns in the evaluation and treatment of POP and SUI depend on academic affiliation and geographic location. Practice patterns are not always based on most recent evidence-based data.

Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion.

INTRODUCTION AND HYPOTHESIS: Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs. RESULTS: This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations. CONCLUSIONS: Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.

Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion.

INTRODUCTION AND HYPOTHESIS: This committee opinion paper summarizes available evidence about recurrent pelvic organ prolapse (POP) to provide guidance on management. METHOD: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development Committee was formed. The literature regarding recurrent POP was reviewed and summarized by individual members of the subcommittee. Recommendations were graded according to the 2009 Oxford Levels of Evidence. The summary was reviewed by the Committee. RESULTS: There is no agreed definition for recurrent POP and evidence in relation to its evaluation and management is limited. CONCLUSION: The assessment of recurrent POP should entail looking for possible reason(s) for failure, including persistent and/or new risk factors, detection of all pelvic floor defects and checking for complications of previous surgery. The management requires individual evaluation of the risks and benefits of different options and appropriate patient counseling. There is an urgent need for an agreed definition and further research into all aspects of recurrent POP.

A strong pelvic floor is associated with higher rates of sexual activity in women with pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: We evaluated the associations between pelvic floor muscle strength and tone with sexual activity and sexual function in women with pelvic floor disorders. METHODS: This was a secondary analysis of a multicenter study of women with pelvic floor disorders from the USA and UK performed to validate the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). Participants were surveyed about whether they were sexually active and completed the PISQ-IR and the Female Sexual Function Index (FSFI) questionnaires to assess sexual function. Physical examinations included assessment of pelvic floor strength by the Oxford Grading Scale, and assessment of pelvic floor tone as per ICS guidelines. RESULTS: The cohort of 585 women was middle-aged (mean age 54.9 ± 12.1) with 395 (67.5 %) reporting sexual activity. Women with a strong pelvic floor (n = 275) were more likely to report sexual activity than women with weak strength (n = 280; 75.3 vs 61.8 %, p < 0.001), but normal or hypoactive pelvic floor tone was not associated with sexual activity (68.8 vs 60.2 %, normal vs hypoactive, p = 0.08). After multivariable analysis, a strong pelvic floor remained predictive of sexual activity (OR 1.89, CI 1.18-3.03, p < 0.01). Among sexually active women (n = 370), a strong pelvic floor was associated with higher scores on the PISQ-IR domain of condition impact (parameter estimate 0.20± 0.09, p = 0.04), and the FSFI orgasm domain (PE 0.51 ± 0.17, p = 0.004). CONCLUSION: A strong pelvic floor is associated with higher rates of sexual activity as well as higher sexual function scores on the condition impact domain of the PISQ-IR and the orgasm domain of the FSFI.

Sexual function in women with anal incontinence using a new instrument: the PISQ-IR.

INTRODUCTION: Anal incontinence (AI) has been associated with sexual complaints. The Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-IUGA Revised (PISQ-IR) has been validated to measure sexual function in sexually active (SA) and non-SA (NSA) women with pelvic floor disorders (PFD) including AI. We describe symptoms in women with PFDs including AI using this instrument. METHODS: This was a planned secondary analysis of data collected for the validation of the PISQ-IR. SA and NSA women with symptoms of pelvic organ prolapse, urinary incontinence (UI) and/or AI at 12 US and 5 UK sites were recruited. The Female Sexual Function Index (FSFI) and PISQ-IR were completed in addition to the Pelvic Floor Distress Inventory (PFDI), and other measures. RESULTS: Of 872 women enrolled, 90 (10%) reported AI. Compared with women without AI, women with AI were more likely to report stress UI (p = 0.007), urgency UI (p < 0.001), mixed UI (p < 0.001), diabetes (p = 0.036) and depression (p < 0.001), and to show larger genital hiatus measurements (p = 0.005) and more underactive pelvic floor muscles (p = 0.011). Furthermore, scores on the PFDI showed greater bother (p = 0.013), particularly the colorectal subscale (p < 0.001). While sexual activity was similar between the groups, FSFI desire (p = 0.016), PISQ-IR 'condition-specific' (p = 0.03) and 'global quality' (p = 0.046) domains were worse in women with AI. In logistic regression analysis, only the PISQ-IR 'condition-specific' domain was associated with AI when controlling for other confounders (OR 0.27, 95% CI 0.10 - 0.72, p = 0.009). CONCLUSIONS: Women with AI have similar rates of sexual activity but poorer sexual function than women without AI. The PISQ-IR may be most appropriate to characterize these conditions.

Mixed urinary incontinence: international urogynecological association research and development committee opinion.

BACKGROUND AND AIM: The definition as well as the treatment of women with mixed urinary incontinence (MUI) is controversial. Since women with MUI are a heterogeneous group, the treatment of MUI requires an individual assessment of the symptom components: stress urinary incontinence, urinary urgency, urgency urinary incontinence, urinary frequency, and nocturia. The purpose of this paper is to summarize the current literature and give an evidence-based review of the assessment and treatment of MUI. METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the diagnosis and management of MUI was drafted based on a literature review. After evaluation by the entire IUGA R&D Committee, revisions were made, and the final document represents the IUGA R&D Committee Opinion on MUI. RESULTS: This R&D Committee Opinion reviews the literature on MUI and summarizes the assessment and treatment with evidence-based recommendations. CONCLUSIONS: The diagnosis of MUI encompasses a very heterogeneous group of women. The evaluation and treatment requires an individualized approach. The use of validated questionnaires is recommended to assess urinary incontinence symptoms and effect on quality of life. Conservative therapy is suggested as a first-line approach; if surgery is contemplated, urodynamic investigation is recommended. Women undergoing surgical treatment for MUI need to be counselled about the possibility of persistence of urinary urgency, frequency and urge incontinence even if stress urinary incontinence is cured.

The PISQ-IR: considerations in scale scoring and development.

INTRODUCTION: This paper provides a detailed discussion of the psychometric analysis and scoring of a revised measure of sexual function in women with pelvic floor disorders (PFD): the Pelvic Organ Prolapse Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). METHODS: Standard tools for evaluating item distributions, relationships, and psychometric properties were used to identify sub-scales and determine how the sub-scales should be scored. The evaluation of items included a nonresponse analysis, the nature of missingness, and imputation methods. The minimum number of items required to be answered and three different scoring methods were evaluated: simple summation, mean calculation, and transformed summation. RESULTS: Item nonresponse levels are low in women who are sexually active and the psychometric properties of the scales are robust. Moderate levels of item nonresponse are present for women who are not sexually active, which presents some concerns relative to the robustness of the scales. Single imputation for missing items is not advisable and multiple imputation methods, while plausible, are not recommended owing to the complexity of their application in clinical research. The sub-scales can be scored using either mean calculation or transformed summation. Calculation of a summary score is not recommended. CONCLUSION: The PISQ-IR demonstrates strong psychometric properties in women who are sexually active and acceptable properties in those who are not sexually active. To score the PISQ-IR sub-scales, half of the items must be answered, imputation is not recommended, and either mean calculation or transformed sum methods are recommended. A summary score should not be calculated.

Female sexual function and dysfunction.

This article identifies models of sexual function, defines and categorizes sexual dysfunction, and identifies therapeutic modalities for patients who have sexual dysfunction. Additionally, it discusses some of the questionnaires used to evaluate sexual function.

Posterior repair and sexual function.

OBJECTIVE: The purpose of this study was to determine the effect of posterior repair (PR) on sexual function in patients who have undergone incontinence and/or pelvic reconstructive surgery. STUDY DESIGN: A cohort study of women who underwent incontinence and/or prolapse surgery was performed. Participants completed the pelvic organ prolapse urinary incontinence sexual questionnaire (PISQ) before and after the operation. PISQ scores were compared between women who underwent PR and women who did not. RESULTS: Of 73 study participants, 30 women underwent PR; 43 women did not (no PR). Although there was no difference in dyspareunia between groups pre-op, dyspareunia prevalence post-op was significantly lower in the no PR group. Preoperative PISQ scores were similar between groups. After the operation, both groups significantly improved their PISQ scores, without a difference between groups. CONCLUSION: Although the incidence of dyspareunia differed between PR and no PR groups, overall improvement in sexual function was reflected in improved total PISQ scores that occurred irrespective of PR performance.

Clinical predictors of urinary retention after pelvic reconstructive and stress urinary incontinence surgery.

OBJECTIVE: To evaluate the impact of perioperative variables on length of postoperative catheterization. STUDY DESIGN: A multicenter, prospective, cohort study of women undergoing pelvic reconstructive and/or incontinence surgery was performed. Perioperative variables associated with length of catheterization and prolonged catheterization (catheterization >30 days) were analyzed. Univariate logistic regression was used identify variables associated with urinary retention. Multivariate logistic regression analysis was performed on variables identified by univariate analysis to construct the best model predicting prolonged postoperative catheterization. RESULTS: Catheterization data were available for 408 patients. Mean catheterization length was 11 +11 days. Thirty-four patients required prolonged catheterization. Logistic regression analysis selected 3 variables as predictors of prolonged catheterization: performance of pubovaginal sling (OR 5.44), performance of vaginal apex suspension (OR 2.32) and preoperative presence of grade 3/4 vaginal apex descent (OR 2.75) (all p < or =0.05). The probability of prolonged catheterization occurring in the absence of any of the predictors was 2% and increased to 5-11% if 1 predictor was present. When all 3 were present, the probability of prolonged catheter use increased to 45%. CONCLUSION: The performance of a pubovaginal sling and of a vaginal apex suspension or the preoperative presence of grade 3/4 vaginal apex descent are associated with prolonged postoperative catheterization.

Does sexual function change after surgery for stress urinary incontinence and/or pelvic organ prolapse? A multicenter prospective study.

OBJECTIVE: The purpose of this study was to assess sexual function in women after surgery for stress urinary incontinence and/or pelvic organ prolapse (UI/POP) at 3 and 6 months with the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ). STUDY DESIGN: Of 269 eligible women participating in a trial of prophylactic antibiotic use with suprapubic catheters, 102 (37.9%) agreed to participate in a sexual function study. Women underwent a variety of anti-incontinence and reconstructive surgeries. Sexual function and urinary incontinence were assessed preoperatively and at 3 and 6 months, postoperatively, with the PISQ and Incontinence Impact Questionnaires (IIQ-7). Paired t tests compared changes over time. Logistic regression compared worsening PISQ versus other variables. Generalized McNemar test compared individual questions preoperatively and postoperatively. Significance was set at P < .05. RESULTS: Mean age was 47.1 (23-85) years, and 64% of women were premenopausal. Seventy-five (74%) women completed questionnaires at 3 or 6 months. Sexual function scores improved after surgery as did IIQ-7 scores (PISQ 89 vs 95, P < .001; IIQ-7 = 52 vs 13, P < .001). The Behavioral Emotive domain scores did not change at 3 to 6 months compared with preoperative scores P = .57), whereas the Physical domain improved (P < .001). Worsening PISQ scores were independent of age, type of surgery, hysterectomy, complications, or hormonal status (logistic regression, all P < .05). CONCLUSION: Sexual function scores in women improve after surgery for UI/POP as did improvement of incontinence at 3 to 6 months after surgery.

Assessment of sexual function in women with pelvic floor dysfunction.

This article reviews sexual function questionnaires used in urogynecology, impact of pelvic floor dysfunction (PFD) on sexual function, and impact of surgical treatment of PFD on sexual function, with a focus on the experience and publications of validated sexual function questionnaires in the urogynecologic literature. A review of the literature was performed to obtain data on sexual function and PFD focusing on those studies that utilized validated sexual function questionnaires. Validated questionnaires assure data that are reliable, quantifiable, and reproducible. Quality-of-life questionnaires, such as The King's Health Questionnaire and the Incontinence Impact Questionnaire, include a few questions addressing sexual function but really deal with the overall impact of incontinence and/or prolapse on the patient's QOL or well-being and do not focus on sexual function. General questionnaires focused on sexual function include the Female Sexual Function Index and the Sexual History Form 12, which were designed to evaluate sexual function and have undergone validation and reliability testing in a general population. General questionnaires are not condition-specific and may not be sensitive enough to detect differences due to PFD. The Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ) is a condition-specific questionnaire focused on sexual function for use in women with PFD and has undergone rigorous validation and reliability testing. Many recent publications examining the impact of urinary incontinence (UI), fecal incontinence, and pelvic organ prolapse (POP) using validated generalized and disease-specific questionnaires have reported poorer sexual function in women with PFD. The PISQ has been used most commonly to evaluate sexual function after surgery for PFD, with increased PISQ scores in approximately 70%. Significant improvement is noted for sexual function related to physical and partner-related factors, with no changes for orgasm, desire, or arousal after surgical repair of PFD. Studies which used generalized sexual function questionnaires mainly found no change in sexual function following surgical treatment of POP and/or UI. In summary, the use of validated questionnaires shows that PFD is associated with a negative impact on sexual functions. Surgical correction of POP and/or UI improves sexual function in approximately 70% of patients, although some studies show no change with the use of non-condition-specific questionnaires.

Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques.

OBJECTIVE: This study was undertaken to compare surgical techniques for the primary repair of obstetric anal sphincter lacerations. STUDY DESIGN: Patients with complete third- or fourth-degree lacerations were recruited and randomly assigned to either an end-to-end or overlapping repair. Data collection included demographic data, obstetric history, and intrapartum events. Postpartum, women completed incontinence questionnaires and underwent physical and ultrasound examinations. To detect a 36% difference between groups with an alpha = .05 and beta = .20, 30 patients were required. Data were analyzed with Student t test and chi2 analysis. RESULTS: Forty-one women were randomly assigned; 23 to an end-to-end and 18 to an overlapping repair. Twenty-seven percent of women underwent episiotomy and 61% operative vaginal delivery. Follow-up was limited to 26 of 41 patients. On physical examination, 3 patients had a separated anal sphincter. On ultrasound, overall 85% of patients had intact sphincters, with no difference between groups (all P > .05). Forty-two percent of women complained of anorectal symptoms with no differences between groups (all P > .28). CONCLUSION: We found no difference in anal incontinence symptoms, physical examination, or translabial ultrasonography findings between the 2 groups. Incontinence symptoms were common in both groups.

A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).

The aim of this study was to develop the short form of a condition-specific, reliable, validated and self-administered instrument to evaluate sexual function in women with pelvic organ prolapse and/or urinary incontinence. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire -12 (PISQ-12) was developed from the data of 99 of 182 women surveyed to create the long form (PISQ-31). An additional 46 patients were recruited for further validation. All subsets regression analysis identified 12 items likely to predict PISQ-31 scores. Short form scores underwent correlation analysis with long form, Incontinence Impact Questionnaire - 7 (IIQ-7), Sexual History Form -12 (SHF-12) and Symptom Questionnaire (SQ) scores. Test-retest reliability was checked with a subset of 20 patients. All subsets regression analysis with R>0.92 identified 12 items that predicted PISQ-31 scores. Short form scores were highly correlated with long form scores ( R=0.75-0.95). Correlations of the PISQ-12 with SHF-12 ( R=-0.66 and -0.68) and IIQ-7 ( R=-0.38 and -0.54) scores were similar to correlation of the PISQ-31 with these other measures. Reliability was moderate to high, with weighted kappa values from 0.56 to 0.93. PISQ-12 scores were lower in patients with low sexual function as measured on the SHF-12 ( P <0.001), and lower in women with depression as measured on the SQ ( P <0.001). The PISQ-12 is a validated and reliable short form that evaluates sexual function in women with urinary incontinence and/or pelvic organ prolapse and predicts PISQ-31 scores. It is able to distinguish women with poor sexual function as measured on the SHF-12.

Sexual function after surgery for stress urinary incontinence and/or pelvic organ prolapse: a multicenter prospective study.

OBJECTIVE: The purpose of this study was to assess sexual function in women after surgery for stress urinary incontinence and/or pelvic organ prolapse (UI/POP) at 3 and 6 months with the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ). STUDY DESIGN: Of 269 eligible women participating in a trial of prophylactic antibiotic use with suprapubic catheters, 102 (37.9%) agreed to participate in a sexual function study. Women underwent a variety of anti-incontinence and reconstructive surgeries. Sexual function and urinary incontinence were assessed preoperatively and at 3 and 6 months postoperatively with the PISQ and Incontinence Impact Questionnaires (IIQ-7). Paired t tests compared changes over time. Logistic regression compared worsening PISQ vs other variables. Generalized McNemar's test compared individual questions pre- and postoperatively. Significance was set at P <.05. RESULTS: Mean age was 47.1 (23 to 85) years, and 64% of women were premenopausal. Seventy-five (74%) women completed questionnaires at 3 or 6 months. Sexual function scores declined after surgery despite improvement in IIQ-7 scores (PISQ=86 vs 78, P <.001; IIQ-7=52 vs 13, P <.001). Behavioral Emotive domain scores worsened at 3 to 6 months compared with preoperative scores, while the Physical domain improved (all P <.001). Worsening PISQ scores were independent of age, type of surgery, hysterectomy, complications, or hormonal status (logistic regression, all P <.05). CONCLUSION: Sexual function scores in women after surgery for UI/POP do not improve despite improvement of incontinence at 3 to 6 months after surgery.

Abdominal hysterectomy for the enlarged myomatous uterus compared with vaginal hysterectomy with morcellation.

OBJECTIVE: The purpose of this study was to compare intraoperative and postoperative complications of abdominal hysterectomy for the enlarged, myomatous uterus with vaginal hysterectomy with morcellation. STUDY DESIGN: Medical records of 139 patients who underwent vaginal hysterectomy with morcellation and 244 patients who underwent total abdominal hysterectomy for an enlarged, myomatous uterus between August 1990 and July 2001 were reviewed. Uterine weights of >982 g were excluded because this was the largest uterus removed vaginally, which left 208 evaluable cases of total abdominal hysterectomy. The perioperative and postoperative course of the two groups was compared. The Student t test was used for continuous variables, and the Fisher exact test was used for binary or categoric data. RESULTS: There were no significant differences between the two groups in surgical or anesthetic risk factors (P>.05). Operative time was similar between the groups (P>.05). Length of hospital stay was increased significantly with total abdominal hysterectomy (mean, 3.9 days vs 2.6 days; P<.001). Perioperative complications were increased with the abdominal route (10% vs 25%, P<.001). CONCLUSION: In this large series, uterine morcellation at the time of vaginal hysterectomy is safe and facilitates the removal of moderately enlarged and well-supported uteri and is associated with decreased hospital stay and perioperative morbidity rate compared with the abdominal route.

A randomized, double-blind, placebo-controlled comparison of the effect of nitrofurantoin monohydrate macrocrystals on the development of urinary tract infections after surgery for pelvic organ prolapse and/or stress urinary incontinence with suprapubic catheterization.

OBJECTIVE: The purpose of this study was to determine if antibiotic prophylaxis with nitrofurantoin monohydrate macrocrystals (study drug) after pelvic organ prolapse and/or urinary incontinence surgery with suprapubic catheterization (SPC) decreases urinary tract infection (uti) compared with placebo in a randomized, double-blind, multicenter trial. STUDY DESIGN: Six centers participated in this study. After a negative preoperative urine culture, history, surgical and postoperative course, urine culture and symptoms at SPC removal, and at 6 to 8 weeks postoperative, any other UTI and adherence were recorded. To demonstrate a 50% decrease in the bacteruria rate from 20%, with 80% power and alpha of 0.05, 438 patients were required. Data were evaluated with Student t test and Fisher exact test. RESULTS: Of 449 patients enrolled, 211 randomized to study drug, and 224 randomized to placebo. No pre- or perioperative differences existed between groups (all P>.05). Antibiotic prophylaxis decreased positive urine cultures compared with placebo (46% vs 61%, P=.002), symptomatic UTI at SPC removal (7.2% vs 19.8%, P=.001), and any other symptomatic UTI 6 to 8 weeks postoperatively (18.9% vs 32.6%, P=.002). Antibiotic prophylaxis did not decrease symptomatic UTI at the 6- to 8-week postoperative visit (1.8% vs 5.4%, P=.10). CONCLUSION: Antibiotic prophylaxis with nitrofurantoin monohydrate macrocrystals decreases UTI compared with placebo after pelvic organ prolapse and/or urinary incontinence surgery with suprapubic catheterization.