Longitudinal study of cognitive decline among women with and without urinary incontinence.

BACKGROUND: Cross-sectional and short-term cohort studies have demonstrated an association between urinary incontinence and dementia, as well as lower performance on cognitive testing. The Health and Retirement Study, a longitudinal study of community-dwelling older adults, offers an opportunity to assess the temporal association between these conditions because it included an assessment of incontinence symptoms and biennial assessments of cognitive function. OBJECTIVE: This study aimed to evaluate if urinary incontinence before the age of 70 years had an effect on changes in cognitive function among women participating in the Health and Retirement Study. STUDY DESIGN: This secondary analysis included data from female respondents in the Health and Retirement Study aged 58 to 67 years with ≥2 cognitive assessments. Urinary incontinence was defined as any involuntary loss of any urine in the preceding 12 months. A control group without incontinence was reweighted for better comparability using coarsened exact matching for age and comorbidities. Validated methods, including neuropsychological test data, estimated a memory score and dementia probability for each participant biennially. Coprimary outcomes were the changes in memory score and dementia probability. Linear regression models were used to estimate the association of urinary incontinence with change in memory score and dementia probability, adjusting for baseline demographics and comorbidities. A subgroup analysis was performed to assess the effects of urinary incontinence frequency on these outcomes. The infrequent subgroup reported <15 days of leakage per month and the frequent subgroup reported ≥15 days of leakage per month. RESULTS: Among eligible female respondents, 40.6% reported urinary incontinence between the ages of 58 and 69 years. Baseline memory scores and dementia probability were similar between those with urinary incontinence (n=1706) and controls (n=2507). Memory score declined significantly in both cohorts, indicating poorer memory over time (-0.222 among those with incontinence [95% confidence interval, -0.245 to -0.199] vs -0.207 in controls [95% confidence interval, -0.227 to -0.188]). The decline of memory score was not statistically significantly different between cases and controls (mean difference, -0.015; 95% confidence interval, -0.045 to 0.015). Dementia probability increased significantly in both groups, indicating a greater probability of developing dementia by 0.018 among those with incontinence (95% confidence interval, 0.015-0.020) and by 0.020 among controls (95% confidence interval, 0.017-0.022). The change in dementia probability was not significantly different between groups (mean difference, -0.002; 95% confidence interval, -0.006 to 0.002). Frequent urinary incontinence was reported in 105 of 1706 (6%) of those with urinary incontinence. Memory score declined and dementia probability increased with time (P<.001) in frequent and infrequent urinary incontinence subgroups. There was no dose-response relationship. CONCLUSION: Measures of cognitive performance declined during approximately 10 years of observation. The changes in performance were not associated with the presence of urinary incontinence in the participants' younger years.

Transition to surgery after pessary among female Medicare beneficiaries with pelvic organ prolapse.

BACKGROUND: The American College of Obstetricians and Gynecologists recommends offering a vaginal pessary to women seeking treatment of pelvic organ prolapse. However, single-institution series have suggested that a sizable proportion of women fitted with a pessary will transition to surgery within the first year. OBJECTIVE: This study aimed to estimate the proportion of female US Medicare beneficiaries with pelvic organ prolapse who undergo surgery after pessary fitting, to describe the median time to surgery from pessary fitting, and to identify factors associated with the transition from pessary to surgery. STUDY DESIGN: The Medicare 5% Limited Data Set was queried from 2011 to 2016 for women aged ≥65 years with a diagnosis of prolapse who underwent pessary fitting. Cases with at least 3 years of follow-up in the Medicare Data Set were followed longitudinally for the primary outcome of surgery for prolapse. The cumulative incidence of prolapse surgery following index pessary fitting was calculated. Characteristics of women who underwent surgery and those who did not were compared using time-varying Cox regression analysis. RESULTS: Among 2032 women fitted with a pessary, 608 underwent surgery within 7 years. The median time to surgery was 496 days (interquartile range, 187-1089 days). The cumulative incidence of prolapse surgery was 12.2% at 1 year and 30.9% at 7 years. After adjusting for covariates, factors significantly associated with the transition to surgery included previous prolapse surgery (adjusted hazard ratio, 1.50; 1.09-2.07) and a diagnosis of urinary incontinence at the time of pessary fitting (adjusted hazard ratio, 1.20; 0.62-0.99). Factors associated with a lower hazard of surgery included age (adjusted hazard ratio, 0.96 per year; 95% confidence interval, 0.95-0.97), dual Medicare/Medicaid eligibility (adjusted hazard ratio, 0.75; 95% confidence interval, 0.56-1.00), and pessary fitting by a nongynecologist (adjusted hazard ratio, 0.78; 95% confidence interval, 0.62-0.99). CONCLUSION: In this population of Medicare beneficiaries, within 7 years of pessary fitting, almost one-third of women aged >65 years underwent surgery for prolapse. These results add to our current understanding of the demographics of pessary use in an older population and may aid in counseling older patients presenting for treatment of symptomatic pelvic organ prolapse.

Prolapse and mesh reoperations following sacrocolpopexy: comparing supracervical hysterectomy, total hysterectomy, and no hysterectomy.

INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy is effective for apical prolapse repair and is often performed with hysterectomy. It is unknown whether supracervical or total hysterectomy at time of sacrocolpopexy influences prolapse recurrence and mesh complications. The primary objective of this study is to compare reoperations for recurrent prolapse after sacrocolpopexy with either supracervical hysterectomy or total hysterectomy, or without concomitant hysterectomy. We also sought to compare these three groups for the incidence of mesh complications and describe cervical interventions following supracervical hysterectomy. METHODS: A retrospective cohort study of sacrocolpopexy was performed using the MarketScan® Research Database. Women > 18 years who underwent sacrocolpopexy between 2010 to 2014 were identified. Utilizing diagnostic and procedural codes, reoperations for prolapse and mesh complications were identified. Women with < 2 years of follow-up were excluded. RESULTS: From 2010 to 2014, 3463 women underwent sacrocolpopexy with at least 2 years of follow-up, 910 (26.3%) with supracervical hysterectomy, 1243 (35.9%) with total hysterectomy, and 1310 (37.8%) without hysterectomy. Reoperations for prolapse were similar after supracervical hysterectomy (1.5%), after total hysterectomy (1.1%, p = 0.40), and without hysterectomy (1.5%, p = 0.98). Mesh complications after sacrocolpopexy were similar after supracervical hysterectomy (1.8%), after total hysterectomy (1.5%, p = 0.68), and without hysterectomy (2.8%, p = 0.11). Following supracervical hysterectomy, 0.9% underwent cervical procedures. CONCLUSIONS: When comparing supracervical and total hysterectomy at time of sacrocolpopexy, there were no significant differences in reoperations for recurrent prolapse, reoperations for mesh complications, or mesh complication diagnoses. This study shows that surgeons can be reassured on performing hysterectomy with sacrocolpopexy.

The impact of anxiety on postoperative pain following pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Despite the prevalence of anxiety, its impact on postoperative pain remains poorly characterized. The present study was aimed at assessing the impact of preoperative anxiety on postoperative pain in patients undergoing pelvic reconstructive surgery. We hypothesized that greater anxiety would be associated with increased postoperative pain for patients undergoing pelvic reconstructive surgery. METHODS: This was a prospective multi-center observational study in Baltimore between September 2018 and June 2019. The Beck Anxiety Inventory was used to assess preoperative anxiety and the validated Surgical Pain Scale instrument was used to assess pain in the postoperative period. The association between anxiety and postoperative pain was analyzed using multivariate logistic regression, adjusting for relevant confounders. RESULTS: A total of 149 patients undergoing pelvic reconstructive surgery completed preoperative surveys. The median age of the study population was 59. The prevalence of preoperative anxiety (anxiety score > 9) in our study population was 26.8% (95% CI 19.7-34.0%). Women with preoperative anxiety reported higher postoperative pain on days 1-2 (relative odds 1.05, 95% confidence interval 1.01-1.10) and day 14 (relative odds 1.53, 95% confidence interval 1.00-2.34). CONCLUSIONS: A large fraction of women undergoing pelvic reconstructive surgery have moderate to severe preoperative anxiety. Women with preoperative anxiety appear to have greater odds of increased postoperative pain. Understanding this association may help surgeons with preoperative counseling and expectations regarding postoperative pain.

Vaginal Complications after Cystectomy: Results from a Medicare Sample.

PURPOSE: Cystectomy with a vaginal-sparing approach may be associated with unique complications specific to the female population. The objective of this study was to estimate the incidence of vaginal complications (defined to include vaginal prolapse, vaginal fistula, dyspareunia and vaginal cuff dehiscence/evisceration) after cystectomy and to determine risk factors for these complications. MATERIALS AND METHODS: Women 65 years or older undergoing cystectomy for any indication were identified by procedural codes in the Medicare Limited Data Set 5% sample from January 1, 2011 to December 31, 2017. Patients experiencing a vaginal complication after cystectomy were compared to those who did not. Demographic and biological factors that could increase likelihood of complications were identified and time to development of complications determined. Cumulative incidence was calculated using cumulative incidence function. Multivariable cause-specific Cox proportional hazards model assessed risk factors for vaginal complications. RESULTS: In all, 481 women undergoing cystectomy were identified during the study period, and 37.2% were younger than 70 years old. The majority (378, 79%) had bladder cancer, and 401 (83.4%) underwent an incontinent conduit or catheterizable channel diversion. Within 2 years of cystectomy, 93 patients (19.5%) had 1 or more complications on record. Vaginal cuff dehiscence had the highest cumulative incidence, occurring in 49 patients (10.2%). Over the entire study period (2011-2017), 102 women (21.2%) were diagnosed with a vaginal complication, and 27 (5.6%) received an intervention. CONCLUSIONS: Among women who undergo cystectomy, vaginal complications occur at rates higher than expected with over 20% of women experiencing a complication and over a quarter of those diagnosed undergoing intervention.

Obstructed defecation syndrome in the first week after pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Research shows that patients are concerned about postoperative bowel function after pelvic reconstructive surgery. The objectives of this study were to estimate the proportion of patients with obstructed defecation syndrome (ODS), a subtype of constipation, in the week after surgery, to identify associated patient-level and perioperative characteristics and the associated bother. METHODS: Women completed a preoperative and postoperative ODS questionnaire and postoperative bowel diary. Characteristics of women with and without postoperative ODS were compared. Chi-squared or Fisher's exact tests compared categorical variables. Student's t test or Wilcoxon rank-sum tests compared continuous variables. Multivariate logistic regression was assessed for independent effects. Wilcoxon rank-sum tests compared the groups with regard to bother. Spearman correlation coefficients described the relationship among bother, postoperative ODS score, and bowel diary variables. RESULTS: Of the 186 participants enrolled, 165 completed the postoperative ODS questionnaire. Of these, 39 women (23.6%, 95% CI 17.2-30.1) had postoperative ODS. Postoperative ODS was significantly associated with preoperative ODS (p < 0.001), posterior colporrhaphy (p = 0.03), surgery type (p = 0.01), and longer duration of surgery (p = 0.03). Using multivariate logistic regression controlling for age, only preoperative ODS was significantly associated with postoperative ODS (OR 2.68, 95% CI 1.73-4.17). Women with postoperative ODS reported more bother with their defecatory symptoms (p < 0.001). The degree of bother was significantly associated with postoperative ODS score (p < 0.001). CONCLUSION: Using a validated disease-specific questionnaire to identify ODS, this complication was identified in 23.6% of patients in the week after pelvic reconstructive surgery. Preoperative ODS was a significant and important risk factor for this complication.

Frailty and postoperative urinary tract infection.

BACKGROUND: Among older adults, postoperative urinary tract infection is associated with significant harms including increased risk of hospital readmission and perioperative mortality. While risk of urinary tract infection is known to increase with age, the independent association between frailty and postoperative urinary tract infection is unknown. In this study we used 2014-2018 data from the U.S. National Surgical Quality Improvement Program (NSQIP) to investigate whether frailty is an independent risk factor for postoperative urinary tract infection, controlling for age and other relevant confounders. METHODS: Frailty was assessed using the modified Frailty Index. Postoperative urinary tract infection was defined as any symptomatic urinary tract infection (of the kidneys, ureters, bladder, or urethra) developing within 30 days of the operative procedure. To examine associations between frailty and other specific factors and postoperative urinary tract infection, chi squared tests, students t-tests, and logistic regression modelling were used. RESULTS: Urinary tract infection was identified after 22,356 of 1,724,042 procedures (1.3%). In a multivariable model controlling for age and other patient and surgical characteristics, the relative odds for urinary tract infection increased significantly with increasing frailty score. For example, compared to a frailty score of 0, the relative odds for urinary tract infection for a frailty score of 3 was 1.50 (95% confidence interval 1.41, 1.60). The relative odds associated with the maximum frailty score (5) was 2.50 (95% confidence interval 1.73, 3.61). CONCLUSIONS: Frailty is associated with postoperative urinary tract infection, independent of age. Further research should focus on the underlying mechanisms and strategies to mitigate this risk among frail adults.

Data on Safety of Intravaginal Boric Acid Use in Pregnant and Nonpregnant Women: A Narrative Review.

ABSTRACT: Intravaginal boric acid (IBA) represents one of the only options available to treat azole-resistant vulvovaginal candidiasis (VVC) and is included as part of multiple national guidelines (including the United Kingdom and the United States) for the treatment of VVC or recurrent bacterial vaginosis. Novel products using IBA are under development for treatment and suppression of VVC and bacterial vaginosis. Use of over-the-counter or clinician-prescribed IBA in reproductive-aged women is already widespread and may increase further if drug resistance in VVC rises. However, IBA is not a Food and Drug Administration-approved drug, and safety data are sparse. Given these factors, it is important to understand the currently available data on the safety of IBA use. Herein, we set out to synthesize human and animal data (converting, where appropriate, dose and serum values to standard units to facilitate comparison) to answer 2 key questions: (1) What are the data on the safety of IBA use for women? and (2) What are the data on the safety of IBA use in pregnancy? We find that, despite gaps, available data suggest IBA use is safe, at least when used in doses commonly described in the literature as being prescribed by clinicians. Information on harms in pregnancy is limited, and data remain insufficient to change current guidelines, which recommend IBA avoidance in pregnancy.

Association between pelvic floor disorders and hernias.

INTRODUCTION AND HYPOTHESIS: Connective tissue disorders may contribute to pelvic floor disorders (PFDs). Like PFDs, abdominal wall hernias are more common in patients with systemic connective tissue disorders. We conducted this study to explore the possible association between PFDs and hernias in adult women. METHODS: We obtained the data for this study from a study of PFDs among parous women. At enrollment, stress urinary incontinence (SUI), overactive bladder (OAB), and anal incontinence (AI) were assessed using the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and pelvic organ prolapse (POP) was assessed through the Pelvic Organ Prolapse Quantification (POP-Q) examination. Participants were asked to report hernia surgery and list their hernia types. We compared the prevalence of PFDs in those with and without hernias using chi-square test. We used multiple regression analysis to adjust for obstetric and sociodemographic variables. RESULTS: Among 1529 women, 79 (5.2%) reported history of hernia surgery. The prevalence of POP was 7.6% (6 cases) vs. 7.4% (107 cases), the prevalence of SUI was 7.6% (6 cases) vs. 9.9% (144 cases), the prevalence of OAB was 7.6% (6 cases) vs. 5.7% (83 cases), and the prevalence of AI was 7.6% (6 cases) vs. 10.8% (156 cases) in those with hernias compared to those without hernias, respectively. None of these differences were statistically significant. There was no association between hernias and PFDs after adjustment for type of delivery, number of deliveries, age group, primary racial background, weight category, and smoking status. CONCLUSION: In this study, we could not find any association between hernias and PFDs.

Surgical Repair of the Genital Hiatus: A Narrative Review.

INTRODUCTION AND HYPOTHESIS: An enlarged genital hiatus (GH) is associated with the development of prolapse and may be associated with prolapse recurrence following surgery; however, there is insufficient evidence to support surgical reduction of the GH as prophylaxis against future prolapse. The objective of this review is (1) to review the association between GH size and pelvic organ prolapse and (2) to discuss the existing literature on surgical procedures that narrow the GH. METHODS: A literature search was performed in the PubMed search engine, using the keyword "genital hiatus." Articles were included if they addressed any of the following topics: (1) normative GH values; (2) associations between the GH and prolapse development or recurrence; (3) surgical alteration of the GH; (4) indications, risks or benefits of surgical alteration of the GH. RESULTS: An enlarging GH has been observed prior to the development of prolapse. Multiple studies show that an enlarged pre- and/or postoperative GH is associated with an increased risk of recurrent prolapse following prolapse repair surgery. There are limited data on the specific risks of GH alteration related to bowel and sexual function. CONCLUSIONS: GH size and prolapse appear to be strongly associated. Because GH size appears to be a risk factor for pelvic organ prolapse, the GH size should be carefully considered at the time of surgery. Surgeons should discuss with their patients the risks and potential benefits of additional procedures designed to reduce GH size.

Pelvic floor muscle strength and the incidence of pelvic floor disorders after vaginal and cesarean delivery.

BACKGROUND: Pelvic floor disorders (including urinary and anal incontinence and pelvic organ prolapse) are associated with childbirth. Injury to the pelvic floor muscles during vaginal childbirth, such as avulsion of the levator ani muscle, is associated with weaker pelvic floor muscle strength. As weak pelvic floor muscle strength may be a modifiable risk factor for the later development of pelvic floor disorders, it is important to understand how pelvic floor muscle strength affects the course of pelvic floor disorders over time. OBJECTIVE: To investigate the association between pelvic floor muscle strength and the incidence of pelvic floor disorders, and to identify maternal and obstetrical characteristics that modify the association. MATERIALS AND METHODS: This is a longitudinal study investigating pelvic floor disorders after childbirth. Participants were recruited 5-10 years after their first delivery and were assessed for pelvic floor disorders annually for up to 9 years. Stress incontinence, overactive bladder, and anal incontinence were assessed at each annual visit using the Epidemiology of Prolapse and Incontinence Questionnaire. Pelvic organ prolapse was assessed on physical examination, and was defined as descent of the vaginal walls or cervix beyond the hymen during forceful Valsalva. The primary exposure of interest was pelvic floor muscle strength, defined as the peak pressure during a voluntary pelvic muscle contraction (measured with a perineometer). The relationship between pelvic floor muscle strength and the cumulative incidence (time to event) of each pelvic floor disorder was evaluated using lognormal models, stratified by vaginal vs cesarean delivery. The relative hazard for each pelvic floor disorder (among those women free of the disorder at enrollment and thus more than 5-10 years from first delivery), was estimated using semiparametric proportional hazard models as a function of delivery mode, pelvic floor muscle strength, and other covariates. RESULTS: Of 1143 participants, the median age was 40 (interquartile range, 36.6-43.7) years, and 73% were multiparous. On perineometry, women with at least 1 vaginal delivery were more likely to have a low peak pressure, defined as <20 cm H2O (243 of 588 women with at least 1 vaginal delivery vs 107 of 555 women who delivered all of their children by cesarean delivery, P < .001). Among women who had at least 1 vaginal delivery, a pelvic floor muscle strength of <20 cm H2O was associated with a shorter time to event for stress incontinence (time ratio, 0.67; 95% confidence interval, 0.50-0.90), overactive bladder (time ratio, 0.67; 95% confidence interval, 0.51-0.86), and pelvic organ prolapse (time ratio, 0.76; 95% confidence interval, 0.65-0.88). No such association was found among women who delivered all of their children by cesarean delivery. Among women with at least 1 vaginal delivery and considering only pelvic floor disorders that developed during study observation (5-10 years after the first delivery), and controlling for maternal characteristics (body mass index and genital hiatus), women who had a peak pressure of <20 cm H2O had hazard ratios (relative to ≥20 cm H2O) of 1.16 (95% confidence interval, 0.74-1.81) for stress incontinence, 1.27 (95% confidence interval, 0.78-2.05) for overactive bladder, and 1.43 (95% confidence interval, 0.99-2.07) for pelvic organ prolapse. Among women who delivered all of their children by cesarean delivery, there was no association between muscle strength and relative hazard of pelvic floor disorders when controlling for maternal characteristics. CONCLUSION: After vaginal delivery, but not cesarean delivery, the cumulative incidence of pelvic organ prolapse, stress incontinence, and overactive bladder is associated with pelvic muscle strength, but the associations attenuate when adjusting for genital hiatus and body mass index.

Association of race with anal incontinence in parous women.

INTRODUCTION AND HYPOTHESIS: To investigate the relationship between race and anal incontinence (AI). Our hypotheses were (a) AI symptoms are similar between white and black women and (b) asymptomatic black and white women are equally likely to develop AI over one year of prospective observation. METHODS: Parous women enrolled in a longitudinal cohort study were assessed for AI symptoms annually using Epidemiology of Prolapse and Incontinence Questionnaire. An AI score > 0 indicated any bother from AI; a score > 22.8 indicated clinically significant AI. We compared the odds of AI scores >0 at the visit level between white vs black women with logistic regression models using generalized estimating equations. We also estimated the odds of new AI symptoms at time T + 1(one year later) among women free of AI symptoms at time T comparing white vs black women. In the latter analysis, we considered new AI symptoms to be represented by scores above 11.4. Covariates included in the adjusted models were: mode of delivery, obstetrical anal sphincter injuries, body mass index, age at the first delivery, and parity at enrollment. RESULTS: Among 1256 participants, 189 (15.0%) were black. AI score = 0 was observed at 74.2% (= 5122/6902) person-visits. The adjusted odds ratio of AI score > 0 was 1.83 (95% CI 1.24, 2.70) for white vs black women. Across 4364 visit pairs with AI score = 0 at time T, 203 (4.7%) had AI score > 11.4 at visit T + 1 and white race significantly increased the odds of developing symptoms at time T + 1 (adjusted OR = 2.26, 95% CI 1.28, 3.98). CONCLUSIONS: In an analysis that controlled for mode of delivery, obstetrical anal sphincter injuries, obesity, age at first delivery, and parity, white race was significantly associated with AI symptoms at any point in time as well as to the development of AI over one year of observation.

Longitudinal Changes in the Genital Hiatus Preceding the Development of Pelvic Organ Prolapse.

We aimed to explore relationships between changes in genital hiatus (GH) and development of pelvic organ prolapse using data from the Mothers' Outcomes After Delivery (MOAD) Study, a Baltimore, Maryland, cohort study of parous women who underwent annual assessments during 2008-2018. Prolapse was defined as any vaginal segment protrusion beyond the hymen or reported prolapse surgery. For each case, 5 controls (matched on birth type and interval from first delivery to study enrollment) were selected using incidence sampling methods. We used a mixed model whose fixed effects described the initial size and slope of the GH as a function of prolapse status (case vs. control) and with nested (women within matched sets) random effects. Among 1,198 women followed for 1.0-7.3 years, 153 (13%) developed prolapse; 754 controls were matched to those women, yielding 3,664 visits for analysis. GH was 20% larger among the cases at enrollment (3.16 cm in cases vs. 2.62 cm in controls; P < 0.001), and the mean rate of increase in the size of the GH was more than 3 times greater (0.56 cm per 5-year period vs. 0.15 cm per 5-year period in controls; P < 0.001). Thus, to identify women at highest risk for developing prolapse, health-care providers could evaluate not simply the size of the GH but also changes in the GH over time.

Pelvic organ prolapse as a function of levator ani avulsion, hiatus size, and strength.

BACKGROUND: Obstetrical levator ani muscle avulsion is detected after 10%-30% of vaginal deliveries and is associated with pelvic organ prolapse later in life. However, the mechanism by which levator avulsion may contribute to prolapse is unknown. OBJECTIVES: This study investigated the extent by which size of the levator hiatus and pelvic muscle weakness may explain the association between levator avulsion and pelvic organ prolapse. STUDY DESIGN: This was a supplementary study of a longitudinal cohort of parous women enrolled 5-10 years after first delivery and assessed annually for prolapse (defined as descent beyond the hymen) for up to 9 annual visits. For this substudy, vaginally parous participants were assessed for levator avulsion using 3-dimensional transperineal ultrasound. Ultrasound was performed at a median interval of 11 years from delivery. Ultrasound volumes also were used to measure levator hiatus area with Valsalva. Pelvic muscle strength was measured with perineometry. Women with and without pelvic organ prolapse were compared for levator avulsion, levator hiatus area, and pelvic muscle strength, using multivariable logistic regression yielding a measure of mediation. Bootstrap methods were used to calculate the confidence interval corresponding to the measure of mediation by hiatus area and pelvic muscle strength. RESULTS: Prolapse was identified in 109 of 429 (25%) and was significantly associated with levator avulsion (odds ratio, 4.17; 95% confidence interval, 2.28-7.31). Prolapse also was associated with levator hiatus area (odds ratio, 1.52 per 5 cm2; 95% confidence interval, 1.34-1.73) and inversely with muscle strength (odds ratio, 0.87 per 5 cm H2O; 95% confidence interval, 0.81-0.94). In a multivariable logistic model including levator avulsion, levator hiatus area, and strength, the association between levator avulsion and prolapse was substantially attenuated and indeed was no longer statistically significant (odds ratio, 1.75; 95% confidence interval, 0.91-3.39). Hiatus area and strength mediated 61% (95% confidence interval, 34%-106%) of the association between avulsion and prolapse. Furthermore, since the 95% confidence interval for this estimate contained 100%, it cannot be ruled out that the 2 markers fully mediate the effect of avulsion on prolapse. CONCLUSIONS: The strong association between pelvic organ prolapse and levator avulsion can be explained to a large extent by a larger levator hiatus and weaker pelvic muscles after levator avulsion.

Breastfeeding and pelvic floor disorders one to two decades after vaginal delivery.

BACKGROUND: Postpartum recovery from pelvic floor trauma associated with vaginal delivery may be impaired by the transient hypoestrogenic state associated with breastfeeding. OBJECTIVE: The aim of our study was to examine the association between exclusive breastfeeding and pelvic floor disorders 1-2 decades after the first vaginal delivery. We hypothesize that compared with women who did not breastfeed following vaginal delivery, women who breastfeed would have a higher proportion of pelvic floor disorders s, and those women who practiced sustained exclusive/unsupplemented breastfeeding would have the highest proportion. STUDY DESIGN: This is a secondary analysis of the Mothers' Outcomes After Delivery study, a prospective cohort study of pelvic floor disorders after childbirth. Participants were recruited 5-10 years after their first delivery and followed up annually for up to 9 years. This analysis focused on participants who experienced at least 1 vaginal delivery. Each participant completed a self-administered questionnaire regarding breastfeeding. Based on questionnaire responses, breastfeeding status was classified into 3 ordinal categories: unexposed (did not breastfeed or breastfed <1 week); limited exclusive breastfeeding (breastfed without supplementation for ≥1 week but <12 weeks); and sustained exclusive breastfeeding (unsupplemented breastfeeding ≥12 weeks). Our primary outcomes of interest were the proportions of stress urinary incontinence, anal incontinence, and pelvic organ prolapse. The outcomes of interest were defined using the Epidemiology of Prolapse and Incontinence Questionnaire and the Pelvic Organ Prolapse Quantification Examination at enrollment and annually for up to 9 years thereafter. Additionally, a subanalysis examined the relationship between breastfeeding and anal incontinence in an obstetric anal sphincter injury-specific population. Generalized estimating equations were utilized to determine the relationship between breastfeeding and the outcomes of interest. RESULTS: Among 705 women, 189 (27%) were classified as unexposed, 145 (20%) were categorized as limited exclusive breastfeeding, and the remaining 371 women (53%) met our definition of sustained exclusive breastfeeding. Median follow-up was 5 years, contributing to a total of 3079 person years. The proportion of each pelvic floor disorder, based on 3079 person-years of follow-up was: stress urinary incontinence (27%), pelvic organ prolapse (20%), or anal incontinence (25%). Using generalized estimating equations adjusting for race, education, parity, and body mass index, sustained exclusive breastfeeding was not significantly associated with stress urinary incontinence (adjusted odds ratio, 0.82, 95% confidence interval, 0.55-1.23), pelvic organ prolapse (adjusted odds ratio, 0.78, 95% confidence interval, 0.49-1.26), and anal incontinence (adjusted odds ratio, 0.67, 95% confidence interval, 0.44-1.00). Regarding our obstetric anal sphincter injury subanalysis, 123 women within our cohort experienced obstetric anal sphincter injuries at delivery. Anal incontinence was reported in 32% of these women. However, there was no observed relationship between breastfeeding and the development of anal incontinence during study follow-up in this population. CONCLUSION: Breastfeeding after vaginal childbirth was not associated with the development of stress urinary incontinence, pelvic organ prolapse, or anal incontinence 1-2 decades after the first vaginal delivery.

Vaginal Candida albicans: High Frequency of in Vitro Fluconazole Resistance in a Select Population-A Brief Note.

Among clinician-ordered vaginal cultures positive for Candida albicans , 30% exhibited fluconazole resistance. Resistance did not reliably predict future susceptibility. Prospective studies to verify associations with demographic and clinical factors as well as to correlate in vitro resistance with treatment response and longitudinal resistance patterns are needed.

Longitudinal study of quantitative changes in pelvic organ support among parous women.

BACKGROUND: Pelvic organ prolapse is more common among parous (vs nulliparous) women and also more common after vaginal (vs cesarean) birth. However, very little is known about how childbirth affects the course and progression of the genital hiatus across a woman's life span. OBJECTIVE: The objective of the sttudy was to investigate the longitudinal, quantitative changes in pelvic organ support after childbirth, focusing on the impact of vaginal vs cesarean delivery. STUDY DESIGN: This was a prospective longitudinal cohort study in which parous women were recruited 5-10 years from first delivery and followed up annually. Using data from annual pelvic organ prolapse quantification examinations, we considered changes in vaginal support at the anterior vaginal wall (point Ba), the vaginal apex (point C), and the posterior wall (point Bp). In univariate and multivariable models, we compared pelvic organ support between women who had delivered at least 1 child vaginally vs those delivered exclusively by cesarean. Other covariates considered included race, age at first delivery, and the size of the genital hiatus. For models of support at Ba and Bp, we also considered the independent association with apical support. For women who delivered vaginally, we also considered forceps birth. RESULTS: A total of 1224 women participated for a total of 7055 woman-visits. In multivariable models, vaginal birth was associated with significantly worse support 5 years from first delivery. Also, women with at least 1 vaginal birth had more rapid worsening of support at point C. The width of the genital hiatus was a significant independent predictor of worse support 5 years from delivery as well as the rate of change over time. In models that controlled for the genital hiatus, the strength of the impact of vaginal birth was attenuated. CONCLUSION: Vaginal birth was associated with worse support 5 years from first delivery and with more rapid deterioration in support at the apex. Above and beyond the impact of vaginal birth, the size of the genital hiatus may be an independent marker for those at greatest risk of prolapse progression.

Longitudinal changes in pelvic floor muscle strength among parous women.

BACKGROUND: There is limited knowledge of the effects of time on change in pelvic floor muscle strength after childbirth. OBJECTIVE: The objectives of this study were to estimate the change in pelvic floor muscle strength in parous women over time and to identify maternal and obstetric characteristics associated with the rate of change. STUDY DESIGN: This is an institutional review board-approved prospective cohort study of parous women. Participants were recruited 5-10 years after first delivery and followed annually. Pelvic floor muscle strength (peak pressure with voluntary contraction) was measured at 2 annual visits approximately 4 years apart with the use of a perineometer. We calculated the change in peak pressures, which were standardized per 5-year interval. Linear regression was used to identify maternal and obstetric characteristics that are associated with the rate of change in peak pressure. The obstetric variable of greatest interest was delivery group. Participants were classified into 3 delivery groups (considering all deliveries for each multiparous woman). Delivery categories included cesarean only, at least 1 vaginal birth but no forceps-assisted deliveries, and at least 1 forceps-assisted vaginal birth. Statistical analysis was completed with statistical software. RESULTS: Five hundred forty-three participants completed 2 perineometer measurements with a median 4 years between measures (interquartile range, 3.1-4.8). At initial measurement, women were, on average, 40 years old and 8 years from first delivery. Initial strength was higher in participants who delivered all their children by cesarean (38.5 cm H2O) as compared with women with any vaginal non-forceps delivery (26.0 cm H2O) or vaginal forceps delivery (13.5 cm H2O; P<.001). There was a strong correlation between the first and second perineometry measurement (r=0.84). Median change in pelvic floor muscle strength was small at 1.2 cm H2O per 5 years (interquartile range, -5.6, 9.9 cm H2O). In multivariable analysis, women who delivered by cesarean only demonstrated almost no change in strength over 5 years (0.2 increase cm H2O per 5 years); those who experienced at least 1 vaginal or vacuum delivery increased strength (4.8 cm H2O per 5 years) as did women with at least 1 forceps delivery (5.0 cm H2O per 5 years). Additionally, obese women had a significant reduction in strength (-3.1 cm H2O per 5 years) compared with normal weight participants (0.2 cm H2O per 5 years). CONCLUSION: Among parous women, pelvic muscle strength increased minimally over time with an average change of 1.2 cm H2O per 5 years; change in strength was associated with mode of delivery and obesity.

Association of Delivery Mode With Pelvic Floor Disorders After Childbirth.

Importance: Pelvic floor disorders (eg, urinary incontinence), which affect approximately 25% of women in the United States, are associated with childbirth. However, little is known about the course and progression of pelvic floor disorders over time. Objective: To describe the incidence of pelvic floor disorders after childbirth and identify maternal and obstetrical characteristics associated with patterns of incidence 1 to 2 decades after delivery. Design, Setting, and Participants: Women were recruited from a community hospital for this cohort study 5 to 10 years after their first delivery and followed up annually for up to 9 years. Recruitment was based on mode of delivery; delivery groups were matched for age and years since first delivery. Of 4072 eligible women, 1528 enrolled between October 2008 and December 2013. Annual follow-up continued through April 2017. Exposures: Participants were categorized into the following mode of delivery groups: cesarean birth (cesarean deliveries only), spontaneous vaginal birth (≥1 spontaneous vaginal delivery and no operative vaginal deliveries), or operative vaginal birth (≥1 operative vaginal delivery). Main Outcomes and Measures: Stress urinary incontinence (SUI), overactive bladder (OAB), and anal incontinence (AI), defined using validated threshold scores from the Epidemiology of Prolapse and Incontinence Questionnaire, and pelvic organ prolapse (POP), measured using the Pelvic Organ Prolapse Quantification Examination. Cumulative incidences, by delivery group, were estimated using parametric methods. Hazard ratios, by exposure, were estimated using semiparametric models. Results: Among 1528 women (778 in the cesarean birth group, 565 in the spontaneous vaginal birth group, and 185 in the operative vaginal birth group), the median age at first delivery was 30.6 years, 1092 women (72%) were multiparous at enrollment (2887 total deliveries), and the median age at enrollment was 38.3 years. During a median follow-up of 5.1 years (7804 person-visits), there were 138 cases of SUI, 117 cases of OAB, 168 cases of AI, and 153 cases of POP. For spontaneous vaginal delivery (reference), the 15-year cumulative incidences of pelvic floor disorders after first delivery were as follows: SUI, 34.3% (95% CI, 29.9%-38.6%); OAB, 21.8% (95% CI, 17.8%-25.7%); AI, 30.6% (95% CI, 26.4%-34.9%), and POP, 30.0% (95% CI, 25.1%-34.9%). Compared with spontaneous vaginal delivery, cesarean delivery was associated with significantly lower hazard of SUI (adjusted hazard ratio [aHR], 0.46 [95% CI, 0.32-0.67]), OAB (aHR, 0.51 [95% CI, 0.34-0.76]), and POP (aHR, 0.28 [95% CI, 0.19-0.42]), while operative vaginal delivery was associated with significantly higher hazard of AI (aHR, 1.75 [95% CI, 1.14-2.68]) and POP (aHR, 1.88 [95% CI, 1.28-2.78]). Stratifying by delivery mode, the hazard ratios for POP, relative to a genital hiatus size less than or equal to 2.5 cm, were 3.0 (95% CI, 1.7-5.3) for a genital hiatus size of 3 cm and 9.0 (95% CI, 5.5-14.8) for a genital hiatus size greater than or equal to 3.5 cm. Conclusions and Relevance: Compared with spontaneous vaginal delivery, cesarean delivery was associated with significantly lower hazard for stress urinary incontinence, overactive bladder, and pelvic organ prolapse, while operative vaginal delivery was associated with significantly higher hazard of anal incontinence and pelvic organ prolapse. A larger genital hiatus was associated with increased risk of pelvic organ prolapse independent of delivery mode.

Patient satisfaction and informed consent for surgery.

BACKGROUND: Informed consent is a process that necessitates time and effort. Underlying this investment is the belief that informing patients about the surgery promotes patient satisfaction with the decision for surgery and potentially satisfaction more broadly. OBJECTIVE: The objective of the study was to investigate the extent to which preoperative satisfaction with a decision to pursue surgery is associated with understanding after an informed consent discussion. STUDY DESIGN: We performed an observational study of adult women seeking surgical treatment for pelvic floor disorders. Study participants were recruited after routine preoperative counseling by board-certified or board-eligible urogynecologists. In our practice, the preoperative informed consent process typically includes a discussion of the indications, risks, benefits, alternatives, and chance of success of the procedures. Participants completed a 35 question survey preoperatively at one setting. The primary outcome, satisfaction with decision, was measured with a validated 6 item Satisfaction with Decision Scale-Pelvic Floor Disorder. Participants were classified as highly satisfied if they indicated the highest level of satisfaction for all items. The primary exposure was patient knowledge of the planned surgery, measured using a newly adapted 20 item Informed Consent Questionnaire including 15 yes/no questions and 5 free-text questions. Additionally, the survey included a validated 3 item tool for health literacy, a single-item anxiety measure, and demographic data. Analyses were performed with a χ2 test, a Student t test, and a multivariable logistic regression using the binary outcome variable, highly satisfied or not highly satisfied. RESULTS: A total of 150 participants were enrolled, with a mean age of 57.5 years. The majority were non-Hispanic (97.3%) or white (87.3%), with at least some college education (51.0%). The median number of days between the informed consent discussion and the survey was 35. The mean total Satisfaction with Decision score was 27.9 (SD, 2.6; range, 19-30), indicating overall high satisfaction with the decision. A patient's preoperative satisfaction with her decision was strongly associated with increased knowledge of the planned surgery, as measured on the Informed Consent Questionnaire (P = .003). The mean score for the highly satisfied group was 17.8 (n = 70; SD, 3.6; range, 6-20) and for the not highly satisfied group was 16.1 (n = 77; SD, 2.8; range, 9-20). There were no significant differences between the highly satisfied and not highly satisfied groups with respect to age, race, education level, anxiety score, or health literacy. The odds of being highly satisfied increased for every 1 point increase in the Informed Consent Questionnaire score (odds ratio, 1.28; 95% confidence interval, 1.06-1.32; P = .003). The association between decisional satisfaction and knowledge persisted after controlling for demographic and clinical variables including education level, health literacy, race/ethnicity, age, surgeon years since completing fellowship, diagnosis, surgery category, number of visits in the past 6 months, and number of days between informed consent discussion and survey. CONCLUSION: This study found that patient knowledge and understanding of surgery are important components of a patient's satisfaction with her decision to proceed with pelvic floor surgery. By measuring patient understanding after informed consent discussions, clinicians may be able to better manage preoperative expectations, increase patient satisfaction, and improve the informed consent process.