Adding Insult to Injury: Levator Ani Avulsion in Women With Obstetric Anal Sphincter Injuries.

OBJECTIVE: In women with obstetric anal sphincter injuries, we compared the rate of major levator ani avulsion after forceps-assisted delivery versus spontaneous vaginal delivery. METHODS: Prospective cohort of primiparous women with obstetric anal sphincter injuries. The primary outcome was the rate of major levator ani avulsion as measured by 3-dimensional transvaginal ultrasonography performed between 1 and 2 weeks postpartum. Secondary outcomes included ultrasonographic anteroposterior hiatal diameter, levator hiatal area, and levator-urethra gap, and differences in validated pelvic disorder questionnaires scores at 1 to 2 and 13 weeks postpartum. RESULTS: Sixty-two women (30 spontaneous deliveries, 32 forceps deliveries) were included in the final analysis. After controlling for delivery variables, women who underwent forceps-assisted delivery were more likely to experience a major avulsion as compared with those who underwent spontaneous delivery (21/32, [65.6%] vs 8/30 [26.7%]; odds ratio, 5.9; 95% confidence interval, 1.5-24.5; P = 0.014). They were also more likely to have larger levator-urethra gaps bilaterally (P = 0.012, 0.016). After controlling for potential confounders, levator ani avulsion was independently associated with persistent anal incontinence symptoms at 13 weeks postpartum (P = 0.02). CONCLUSIONS: In women with obstetric anal sphincter injuries, the risk of levator ani avulsion is almost 6 times higher after forceps-assisted vaginal delivery as compared with spontaneous vaginal delivery. In those with avulsion, recovery of anal continence is compromised, suggesting that adding insult (avulsion) to injury (obstetric anal sphincter injury) may have negative functional consequences.

Concomitant Repair of Pelvic Floor Disorders in Women Undergoing Surgery for Gynecologic Malignancies.

OBJECTIVE: The aims of this study were to determine the rate and describe 30-day postoperative complications of concomitant pelvic organ prolapse and/or urinary incontinence (POPUI) procedures in women undergoing surgery for a gynecologic malignancy. METHODS: Women who underwent surgical intervention for a gynecologic malignancy between 2010 and 2014 were identified using postoperative International Classification of Diseases, Ninth Revision codes 179.0 to 184.9 in the American College of Surgeons National Surgical Quality Improvement Program database. Women who underwent POPUI procedures were identified using Current Procedural Terminology codes between 51840 and 58294. Infectious, pulmonary, cardiac, and venous thromboembolism complication rates were calculated. Patient demographics and postoperative complication rates were analyzed using Student t, χ, and Fisher exact tests and compared between women with a gynecologic malignancy who did and did not undergo concomitant POPUI procedures. RESULTS: We identified 23,501 women with a diagnosis of a gynecologic malignancy. The most common included uterine (63%), ovarian (25%), and cervical cancer (8%). Only a small proportion of the women undergoing gynecologic cancer surgery (n = 556 [2.4%]) had concomitant POPUI procedures. The most commonly performed POPUI procedures included anterior and/or posterior colporrhaphy (n = 205 [32%]), laparoscopic colpopexy (n = 181 [28.2%]), and midurethral sling (n = 70 [10.9%]). There were no differences in 30-day reoperation; infectious, pulmonary, and cardiac complications; or venous thromboembolic events between women who did and did not have concomitant POPUI surgery. CONCLUSIONS: Using a large national surgical database, only 2.4% of women undergoing gynecologic cancer surgery had a concomitant POPUI procedure. Our data suggest that postoperative complications may not increase when concomitant surgery for POPUI is done at the time of gynecologic cancer surgery.

Anal Penetrative Intercourse as a Risk Factor for Fecal Incontinence.

OBJECTIVE: The aim of the study is to investigate the relationship between anal penetrative intercourse (API) and pelvic floor symptoms, specifically, anal incontinence (AI). METHODS: This was an institutional review board-approved, cross-sectional, e-mail survey of women enrolled in the Illinois Women's Health Registry. Participants were anonymously queried about their sexual practices and the effects of these on bowel and bladder symptoms. Urinary symptoms were assessed using the urogenital distress inventory-6 and bowel symptoms with the fecal incontinence severity index (FISI). RESULTS: One thousand three women (mean age of 46 ± 15 years) completed the survey. Eighty percent were white, 56% were married, and 99% reported ever being sexually active. Thirty-two percent had API at least once, and 12% considered it "part of their sexual practice." Sixty percent of the cohort reported a bothersome urinary symptom on the urogenital distress inventory-6, 70% reported AI on the FISI, and 15% reported fecal incontinence. Of women who engaged in API, 18% reported it changed their stool consistency, and 10% reported it caused AI. Having engaged in API within the last month was correlated with higher FISI scores (P = 0.05) and with fecal incontinence on the FISI (28.3% vs 14.4%; P = 0.01; odds ratio, 2.48). In addition, API was more commonly practiced among women who reported that vaginal intercourse caused dyspareunia (17% vs 12%, P = 0.05) or changes in bladder symptoms such as urgency or dysuria (44% vs 30%, P < 0.001). CONCLUSIONS: Self-reported AI and FI (as measured by the FISI scores) are higher in women who have had API, and frequency of API may be important in determining the risk of bowel symptoms.

Changing Referral Patterns to Urogynecology.

OBJECTIVE: The study aims to identify sources of and changes in referral patterns for pelvic floor disorders. METHODS: All new patient visits to urogynecology at our institution between January 2010 and December 2015 were identified. Patient demographics, referral source, insurance type, and visit diagnoses using ICD-9 codes were abstracted. ICD-9 codes were grouped into 18 urogynecologic diagnoses. Data were analyzed using SPSS (Version 20; Chicago, IL). RESULTS: Five thousand seven hundred ninety-nine new patient visits were included in the analysis. The mean age was 54 ± 17 years and 59% were Caucasian. Forty-four percent were referred by obstetrician/gynecologists (OB/GYNs), 32% by primary care providers (PCPs), 14% by self-referral, and 9% by other specialties. New patient visits increased overall by 280% over 6 years; self- and PCP referrals increased by 480% and 320%, respectively. In comparison, OB/GYN referrals increased by only 229%. Patients diagnosed with prolapse and stress incontinence were more likely to be referred by an OB/GYN (P < 0.001), whereas PCPs were more likely to refer for urinary tract infections (P < 0.005) and urgency urinary incontinence (P < 0.001) than OB/GYNs. CONCLUSIONS: Demand for pelvic floor specialists is growing quickly, with PCP and self-referrals outpacing referrals from obstetrician-gynecologists to tertiary care urogynecology practices.

Perioperative complications following colpocleisis with and without concomitant vaginal hysterectomy.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse is common in the elderly population and may be surgically treated with colpocleisis. We aimed to identify and compare surgical characteristics and 30-day perioperative complications in patients who underwent colpocleisis with and without concomitant vaginal hysterectomy (VH) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS: Women who underwent vaginal closure procedures from 2006 to 2014 were identified utilizing Current Procedural Terminology (CPT) codes for LeFort colpocleisis (57120) and vaginectomy (57110). Patients undergoing a concomitant VH were identified by CPT codes ranging from 58260 to 58294. Variables including patient demographics, operative time, hospital length of stay, transfusion' and reoperation were evaluated. Specific medical complications, surgical site infection' and urinary tract infection (UTI) rates were calculated. Variables were analyzed using chi-squared, Fisher's exact, student's t tests and logistic regression. RESULTS: We identified 1,027 women in the ACS-NSQIP database who underwent vaginal closure procedures. The majority of patients (893, 87.0%) underwent colpocleisis alone, and the remainder (134, 13.0%) underwent concomitant VH. Operative times were shorter in patients undergoing colpocleisis alone. UTI was the most common postoperative complication affecting 4.3% of the entire cohort. Twelve women (1.2%) had a serious medical complication, seven who underwent colpocleisis alone and five who underwent colpocleisis with concomitant VH. In backward logistic regression' serious medical complications were the only variable independently associated with VH at the time of colpocleisis (p < 0.05). CONCLUSIONS: Colpocleisis is a safe procedure with rare serious adverse events.

Postoperative appointments: which ones count?

INTRODUCTION AND HYPOTHESIS: Although postoperative complications in women undergoing reconstructive pelvic surgery (RPS) have been characterized, little is known regarding the timeline of these occurrences. We aimed to determine the timeframe after RPS during which the majority of complications occur, to assist with planning intervals between postoperative visits. METHODS: Women undergoing RPS were identified through billing information. Demographic, surgical, and complications data were extracted from electronic medical records. The Pelvic Floor Complication scale is a surgical scale tailored to women undergoing RPS. It contains three subscales: intraoperative, immediately postoperative, and delayed complications. We applied this scale to each postoperative visit (at 2, 6, and 13 weeks). RESULTS: 396 women underwent RPS and 125 patients had 179 complications, most of which (66 %) were identified by the 2-week visit. Complications at the 2-week visit consisted of urinary tract infection (UTI; 46 %), wound infection (10.0 %), and urinary retention (9.4 %). The majority of serious complications (venous thromboembolism [VTE], ileus, small bowel obstruction [SBO], readmission, and reoperation [1 incarcerated hernia and 1 sling release]) were diagnosed by 2 weeks. One patient was readmitted for ileus at between 2 and 6 weeks. At between 6 and 13 weeks, 1 patient was readmitted with SBO; 1 VTE was diagnosed; and 1 required reoperation for a prolapsed fallopian tube. In contrast, two thirds of the complications seen at the 13-week visit were due to granulation tissue, suture erosion or mesh erosion. CONCLUSIONS: The majority of non-mesh-related complications occur within the first 2 weeks after RPS, whereas mesh and suture complications are more likely to be identified at the 13-week visit.

Anal Sphincter Injuries After Operative Vaginal Versus Spontaneous Delivery-Is There a Difference in Postpartum Symptoms?

OBJECTIVE: The aim of this study was to determine whether there is a difference in pelvic floor symptoms between women who had obstetric anal sphincter injuries (OASIS) after an operative vaginal delivery versus those who had OASIS after a spontaneous delivery. METHODS: This was a secondary analysis of a prospective cohort study of women who sustained OASIS. Women were evaluated at 1 week postpartum and again at 12 weeks; at both of these visits, they completed a battery of validated questionnaires including a visual analog scale for pain, Patient Health Questionnaire 9 depression inventory, Fecal Incontinence Severity Index, Urogenital Distress Inventory 6, and Incontinence Impact Questionnaire 7. RESULTS: Two hundred sixty-eight women with OASIS were included in this analysis (194 operative vaginal, 74 spontaneous). Ninety-one percent of those with operative vaginal delivery had a forceps-assisted delivery. After multivariate regression, operative OASIS was independently associated with greater Urogenital Distress Inventory 6 scores (P = 0.02), Fecal Incontinence Severity Index scores (P = 0.04), and visual analog scale pain scores (P = 0.03) and higher rates of urgency urinary incontinence (P = 0.04), stress urinary incontinence (P = 0.02), and anal incontinence (P = 0.04) at 1 week postpartum. At 3 months postpartum, symptoms were no different between the groups. CONCLUSIONS: Women who sustain OASIS secondary to operative vaginal delivery report more bothersome urinary symptoms and higher rates of anal incontinence immediately postpartum as compared with women with OASIS secondary to spontaneous delivery. These differences may resolve by 3 months postpartum.

Effect of anesthesia type on perioperative outcomes with a midurethral sling.

INTRODUCTION AND HYPOTHESIS: There is no consensus on the most appropriate type of anesthesia for placement of a midurethral sling. Our objective was to compare intra- and perioperative outcomes for this procedure performed under general anesthesia versus monitored anesthesia care. METHODS: Retrospective cohort analysis of women undergoing outpatient placement of synthetic retropubic midurethral sling under general anesthesia (n = 141) or monitored anesthesia care (n = 84). Patients undergoing concomitant procedures were excluded. Primary outcome was operating room time. Secondary outcomes included surgical and recovery times, cost, discharge home with a catheter, and postoperative pain and/or nausea. RESULTS: In the general anesthesia group, both operating room time (mean ± SD, 67.6 ± 13.3 min vs 56.9 ± 11.8 min, p < 0.001) and recovery room time (240.0 ± 69.8 min vs 190.1 ± 78.3 min, p < 0.001) were longer, whereas there was no difference in surgical time (30.0 ± 8.9 min vs 29.0 ± 9.7 min, p = 0.43). Cost was significantly higher in the general anesthesia group ($4,095 ± 715 vs $3,877 ± 777, p = 0.03). There was no difference in rates of bladder perforation (6.4 % vs 11.9 %, p = 0.33). Patients who underwent general anesthesia had higher rates of discharge with a catheter (27.0 % vs 15.8 %, p = 0.04). CONCLUSION: Monitored anesthesia care may offer significant benefits over general anesthesia in women undergoing retropubic midurethral sling, including shorter operating room and recovery times, lower costs, and less voiding dysfunction in the immediate postoperative period.