Symptomatic urinary tract infections after surgery for prolapse and/or incontinence.

INTRODUCTION AND HYPOTHESIS: The purpose of our study was to estimate the frequency and risk factors for symptomatic urinary tract infection (UTI) after surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP). METHODS: Case-control study of 389 consecutive women who underwent surgery for POP and/or SUI. Cases were defined as a symptomatic, culture-confirmed UTI within 6 weeks of surgery. Multivariable logistic regression was used to determine independent risk factors. RESULTS: Thirty five (9%) women developed a UTI. The risk of UTI was significantly increased by previous history of multiple UTIs (adjusted OR: 3.7, CI 1.4-10.1), increased distance between the urethra and the anus (adjusted OR: 1.4, CI 1.1-1.9), and prolonged duration of catheterization (adjusted odds ratio (OR) for >or=10 days: 4.2, 95% CI 1.5-11.6); 94.6% of catheterizing women were prescribed daily nitrofurantoin. CONCLUSIONS: UTI is an important postoperative morbidity after urogynecologic surgery and is common in catheterizing women despite antibiotic prophylaxis.

Depressive symptoms in women seeking surgery for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: To compare depressive symptoms in women with and without prolapse and evaluate impact on quality of life. METHODS: This is a secondary analysis of a case-control study assessing the effect of prolapse on body image. Cases had prolapse and sought surgery (Pelvic Organ Prolapse Quantification stage > or = 2). Controls had stage < or = 1. Subjects completed the Pelvic Floor Impact Questionnaire (PFIQ), Pelvic Floor Distress Inventory, and the Patient Health Questionnaire-9 (PHQ-9) at baseline. Cases completed measures 6 months post-operatively. We report: (1) the comparison of cases and controls at baseline and (2) comparison of baseline and post-operative scores in cases. RESULTS: Baseline questionnaires were completed by 75 cases and 65 controls; 57 cases completed post-operative measures. Cases were 5-fold more likely than controls to have depressive symptoms. Cases with depressive symptoms had higher PFIQ scores than cases without symptoms. PHQ-9 scores improved post-operatively. CONCLUSIONS: Depressive symptoms are common in women with prolapse and a decrease following surgical treatment.

Effect of pessary use on genital hiatus measurements in women with pelvic organ prolapse.

OBJECTIVE: To compare the size of the genital hiatus in women wearing a pessary for pelvic organ prolapse after consistent pessary use, describe characteristics of patients who continue use, and assess change in pelvic floor symptoms. METHODS: This was an observational cohort study of 90 women seeking nonsurgical management of symptomatic prolapse. Our primary outcome was change in genital hiatus (in centimeters) after 3 months of consistent pessary use. Pelvic floor symptoms were assessed with the Pelvic Floor Distress Inventory. Change in genital hiatus measurements and Pelvic Floor Distress Inventory scores were assessed using a paired Student t test. Between-group differences were evaluated using the Student t, Mann Whitney U, and Fisher exact tests, where appropriate. Logistic regression was used to assess baseline characteristics predictive of continued pessary use. RESULTS: The average (+/-standard deviation) age of participants enrolled was 62.8 +/-13.2 years. Median parity was 3, and 87.7% were postmenopausal. Forty-two (47%) continued pessary use at 3 months. After 2 weeks, there was a decrease in the size of the genital hiatus measured with strain from 4.8+/-1.6 cm to 4.1+/-1.2 cm, P<.001, which persisted at 3 months (3.9+/-1.1 cm, P<.001). The greatest change occurred with the Gellhorn pessary. Baseline Pelvic Organ Prolapse Quantification system point Aa was positively associated with continued pessary use at 3 months, and perineal body at rest was negatively associated. CONCLUSION: After 3 months of pessary use, genital hiatus size decreased significantly. Pessary use results in significant anatomic changes to the genital hiatus in patients with pelvic organ prolapse.

The role of apical vaginal support in the appearance of anterior and posterior vaginal prolapse.

OBJECTIVE: To describe how simulated apical support affects the appearance of prolapse in the anterior and posterior vagina using a modification of the Pelvic Organ Prolapse Quantification (POP-Q) examination. METHODS: Women with prolapse stage II or greater were examined using the POP-Q. To simulate apical support, the posterior blade of a standard Graves speculum was positioned over the posterior vagina to support the vaginal apex while remeasuring points Aa and Ba and over the anterior vagina to support the apex while remeasuring points Ap and Bp. Change in anterior and posterior POP-Q points and prolapse stage with apical support were calculated. RESULTS: One hundred ninety-seven women were enrolled with mean age of 62+/-14 years, median parity of 2 (range 0-8), and mean body mass index of 28+/-5 kg/m(2). By standard POP-Q, 36% had stage II prolapse, 54% had stage III, and 10% had stage IV prolapse. With simulated apical support, point Ba changed to stage 0 or I in 55% of cases and point Bp changed to stage 0 or I in 30% (P<.001 for each point). Mean change for point Ba with apical support was 3.5+/-2.6 cm and point Bp was 1.9+/-2.9 cm (P<.001). CONCLUSION: When the POP-Q examination is performed with simulated apical support, the critical role of level I vaginal support on the position of the anterior and posterior vagina, particularly the anterior vagina, becomes apparent. LEVEL OF EVIDENCE: II.

Two-year outcomes after vaginal prolapse reconstruction with mesh pelvic floor repair system.

OBJECTIVE: The aim of this study was to assess anatomical and functional outcomes 2 years after prolapse repair using vaginal mesh repair system. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Pelvic support and urinary function improve in women after surgically induced weight reduction.

OBJECTIVE: : The objective of this study was to assess pelvic organ support and symptoms in morbidly obese women before and after weight reductive surgery. METHODS: : Fifty-four women were enrolled in this institutional review board-approved protocol. Data collection at baseline and 6 months following surgery included a Pelvic Organ Prolapse Quantification examination, questionnaires including the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, and the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire short form, and a 3-day voiding diary. Before-surgery and after-surgery measures were compared using paired Student t tests for continuous, normally distributed data or the Wilcoxon signed rank test for ordinal data. RESULTS: : Baseline and 6-month data were available for 34 women. The mean body mass index was 46 ± 6 kg/m at baseline and 33 ± 6 kg/m after 6 months. Subjects with ≥stage 2 prolapse at baseline demonstrated an improvement of 0.5 cm (baseline, 0.9 ± 0.8 cm; after 6 months, -1.4 ± 0.9 cm) in the anterior vaginal compartment (points Aa/Ba) 6 months following weight reductive surgery (P = 0.05). Of 24 women who completed 3-day voiding diaries, 12 were incontinent at baseline with a median number of incontinent episodes of 6.5 per day (range, 3-34). After surgery, 6 incontinent women became continent. In the 6 women who remained incontinent after surgery, the number of incontinent episodes per day decreased by a median of 2.5 (range, 1-11). Pelvic Floor Distress Inventory scores improved following weight reduction (baseline, 115 ± 80; after 6 months, 58 ± 70; P < 0.01). DISCUSSION: : Obese women, after surgically induced weight loss, demonstrate an improvement in anterior vaginal support, urinary leakage and pelvic floor symptoms.

Perioperative outcomes of the Prolift pelvic floor repair systems following introduction to a urogynecology teaching service.

The safety information of the vaginal mesh systems upon introduction to a teaching urogynecology service is limited to date. To determine the frequency of perioperative complications associated with the use of Prolift kits (Gynecare/Ethicon, Somerville, NJ, USA) by a teaching urogynecology service, data from the first 100 consecutive women were analyzed. The primary outcome was any deviation from a normal intraoperative or perioperative course. Complications were graded using the Dindo morbidity scale. Univariate analyses were performed to identify risk factors. Complications included bladder perforation (2%), blood transfusion (2%), mesh exposure (4%), and urinary tract infections (28%). Eleven percent of women reported postoperative pain, and 34% required catheterization at discharge for incomplete bladder emptying. Univariate analysis showed no association between morbidities and patient characteristics, attending experience, or fellow involvement. The integration of Prolift kits for prolapse repair into a urogynecology training program can be achieved with few perioperative complications.