Multidisciplinary approach to evaluation of rectovaginal fistulas.

Thorough evaluation of a rectovaginal fistula is essential to optimize surgical repair. The underlying cause should be addressed and treated, which can affect the timing and the approach to repair. It is imperative to be well prepared because the highest chance of successful closure occurs during the initial repair attempt. Our objective was to demonstrate how multidisciplinary colorectal surgery and urogynecology teams use specific methods during the examination under anesthesia to evaluate a complex rectovaginal fistula and to optimize the surgical approach to repair. Anesthesia may be provided with monitored anesthesia care and a posterior perineal block. This pain control allows for a wide range of techniques to evaluate the fistula using anoscopy, fistula probe, hydrogen peroxide, and sigmoidoscopy. In addition, the teams show how curettage and subsequent seton placement can encourage closure by secondary intention and decrease the risk of abscess formation, respectively.

Is Nocturia Associated With Detrusor Underactivity?

OBJECTIVES: Detrusor underactivity (DU) is diagnosed using urodynamic testing. We hypothesized that nocturia is associated with detrusor underactivity. METHODS: We performed a retrospective chart review of all women who underwent urodynamic testing at our institution between 2016 and 2018. Uroflowmetry and pressure-flow study parameters were compared between women with nocturia (≥2 voids/night) and without nocturia (0-1 void/night). Detrusor underactivity was diagnosed using 3 different criteria: (1) bladder voiding efficiency (BVE) of <90%, (2) bladder contractility index of <100, and (3) a composite of three urodynamic measures (Gammie criteria). RESULTS: Of 358 women, 172 (48%) were in the nocturia group and 186 (52%) were in the no nocturia group. On uroflowmetry, median postvoid residual volume was similar (20 mL) in both groups. Median maximum flow rate (15 vs 17 mL/s, P < 0.05) and average flow rate (6 mL/s vs 7 mL/s, P < 0.05) were significantly lower in the nocturia group compared with the no nocturia group. During pressure-flow study, a significantly greater proportion of women with nocturia were unable to void around the catheter (30% vs 27%, P < 0.01). The overall rate of DU varied with the criteria used: BVE (54%), bladder contractility index (41%), and Gammie criteria (7%). The rate of DU using the BVE criteria was significantly higher in the nocturia group (63% vs 48%, P < 0.01), but no significant differences were noted using the other criteria. CONCLUSIONS: Nocturia is associated with reduced voiding efficiency in women. The diagnosis of DU using urodynamics is challenging.

Relationship Between Pelvic Organ Prolapse and Non-Human Papillomavirus Pap Smear Abnormalities.

OBJECTIVE: The aim of this study was to determine the association between pelvic organ prolapse (POP) and non-human papillomavirus (HPV) Papanicolaou (Pap) smear abnormalities. METHODS: This was a retrospective cohort study of women aged 40 to 70 years who presented for consultation at our institution between 2010 and 2015 and had results of a Pap smear and HPV test available within 5 years of their visit. We extracted demographic information, medical and social history, Pap smear, and HPV results from the electronic medical record. Associations between the presence of POP and non-HPV Pap smear abnormalities were estimated using univariable and multivariable analyses. RESULTS: We reviewed 1590 charts and excluded 980 women, leaving 610 women in the study: 183 with POP and 427 without POP. Women with POP were significantly older (58.2 ± 7.2 vs 55.6 ± 6.6, P < 0.01) and more likely to have a remote (>10 year) history of abnormal Pap smear (24.0% vs 14.8%, P < 0.01). The rate of non-HPV-associated abnormal Pap smears was higher in the POP group than in the non-POP group (12/183 [6.6%] vs 12/427 [2.8%], P = 0.029). In the POP group, the rate of non-HPV Pap smear abnormality was significantly associated with increasing prolapse stage (stage 1: 0/16 [0%], stage 2: 5/77 [6.5%], stage 3: 3/73 [4.1%], stage 4: 4/17 [23.5%]; P = 0.02). After controlling for age and remote history of abnormal Pap smear, the odds ratio for non-HPV Pap smear abnormalities in the POP group remained significant (2.49; 95% confidence interval, 1.08-5.79). CONCLUSIONS: Human papillomavirus-negative Pap smear abnormalities may be related to POP. Our findings have important implications for surgeons seeking to leave the cervix in situ in women with POP.

Vaginoplasty with an Autologous Buccal Mucosa Fenestrated Graft in Two Patients with Vaginal Agenesis: A Multidisciplinary Approach and Literature Review.

Here we describe the procedure and outcomes of a multidisciplinary approach to vaginoplasty using autologous buccal mucosa fenestrated grafts in 2 patients with vaginal agenesis. This procedure resulted in anatomic success, with a functional neovagina with good vaginal length and caliber and satisfactory sexual function capacity and well-healed buccal mucosa. There were no complications, and the patients were satisfied with the surgical results. We conclude that the use of a single fenestrated graft of autologous buccal mucosa is a simple, effective procedure for the treatment of vaginal agenesis that results in an optimally functioning neovagina with respect to vaginal length, caliber, and sexual capacity.

Sexual activity and vaginal topography in women with symptomatic pelvic floor disorders.

INTRODUCTION: Pelvic floor disorders affect vaginal anatomy and may affect sexual function. AIMS: The aims of this study were to explore the relationship between vaginal anatomy and sexual activity in women with symptomatic pelvic floor disorders and to assess whether vaginal measurements (topography) correlate with sexual function. METHODS: This is a retrospective cohort study comparing sexually active and nonsexually active women planning urogynecologic surgery. Our primary outcome was the difference in vaginal topography based on Pelvic Organ Prolapse Quantification (POP-Q) exam between cohorts. Correlations between POP-Q measurements and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) scores were assessed in sexually active women. MAIN OUTCOME MEASURE: The POP-Q is a quantitative and standardized examination for prolapse. The PISQ-12 is a condition-specific sexual function questionnaire validated in sexually active women with pelvic floor disorders. RESULTS: Of 535 women, 208 (39%) were sexually active and 327 (61%) were not. Median genital hiatus (GH) and perineal body (PB) measurements and a PB:GH ratio were not significantly different between the two cohorts. Total vaginal length (TVL) was longer in sexually active women (median 9 vs. 8 cm, P<0.001). In a linear regression analysis controlling for potential confounders, sexually active women still had a longer TVL by 0.4 cm (95% confidence interval 0.07, 0.6 cm) compared with those who were not sexually active. Of the 327 nonsexually active women, 28% indicated they avoided sexual activity because of pelvic floor symptoms. There was poor correlation between TVL, GH, PB, and PB : GH ratio with PISQ-12 scores (r=0.10, -0.05, -0.09, -0.03, respectively). CONCLUSIONS: In women with pelvic floor disorders, sexual activity is associated with a longer vaginal length. One-quarter of women indicated they avoided sexual activity because of pelvic floor symptoms. Vaginal topography does not correlate with sexual function based on PISQ-12 scores.

Does concomitant anterior/apical repair during midurethral sling improve the overactive bladder component of mixed incontinence?

INTRODUCTION AND HYPOTHESIS: Midurethral sling (MUS) can improve overactive bladder (OAB) symptoms. It is unclear if anterior/apical prolapse (AA) repair provides additional benefit. We hypothesized that women with mixed urinary incontinence (MUI) experience greater improvement in the OAB component of their symptoms after concomitant MUS and AA repair compared with MUS alone. METHODS: This is a retrospective cohort study of women with bothersome MUI (defined by objective stress test and validated questionnaire) undergoing MUS alone ("MUS-only") or concomitant MUS and AA repair ("MUS + AA"). Our primary outcome was the Overactive Bladder Questionnaire Symptom Severity (OAB-q SS) change score 6 weeks after surgery. RESULTS: Of 151 women, 67 (44 %) underwent MUS-only and 84 (56 %) underwent MUS + AA. The MUS-only cohort was younger and had less severe baseline prolapse (p < 0.05 for both). Postoperative complications (predominantly UTI) occurred in 35 (23 %) patients and were similar between cohorts. For all subjects mean OAB-q SS scores significantly improved postoperatively (p < 0.05). Our primary outcome, OAB-q SS change score, showed no significant differences between cohorts (30 ± 26 MUS-only vs 25 ± 25 MUS + AA, p = 0.20), indicating similar improvements in OAB symptoms. Multivariate linear regression analysis revealed no difference in OAB-q SS change score between cohorts; however, OAB-q SS change scores were lower for women with a postoperative complication (ß = -19, 95 % CI -31 to -6; p < 0.01). CONCLUSIONS: In women with bothersome MUI, concomitant AA repair does not result in additional improvement in OAB symptoms over MUS alone. Patients with postoperative complications exhibit less improvement in OAB symptoms.

Is postoperative bowel function related to posterior compartment prolapse repair?

OBJECTIVES: This study aimed to assess how posterior repair (PR) affects change in bowel function in women undergoing anterior/apical surgery for prolapse. METHODS: We performed a retrospective cohort study of women undergoing prolapse surgery. Our 2 cohorts were women who underwent anterior/apical prolapse surgery either with or without a PR. All women completed the short form of the Colorectal-Anal Distress Inventory (CRADI-8) preoperatively and 6 weeks postoperatively. We compared change in CRADI-8 scores between those who received PR versus those who did not. RESULTS: Among 238 women who underwent anterior/apical prolapse surgery, 61 (26%) underwent PR, whereas 177 (74%) did not undergo PR. There were no significant differences in mean CRADI-8 scores at baseline or postoperatively, and scores improved significantly in both groups [baseline scores 23.2 (20.2) for PR vs 18.2 (19.3) for no PR, P = 0.12; postoperative scores 5.0 (10.5) for PR vs 8.4 (15.4) for no PR, P = 0.08]. For our primary outcome, we identified a significantly larger margin of symptom improvement in those who underwent PR compared to those who did not [mean CRADI-8 change scores 18.2 (20.1) for PR vs 9.9 (18.6) for no PR, P < 0.01]. In a linear regression model assessing postoperative CRADI-8 scores, women who underwent PR scored 4.9 points lower on the postoperative CRADI-8, suggesting more improvement in bowel-related symptoms, compared to those who did not undergo PR (95% confidence interval, 1.0, 8.8, P = 0.02). CONCLUSIONS: Women undergoing surgery for anterior/apical prolapse demonstrated significant improvements in bowel symptoms after surgery. Those receiving concomitant PR had a significantly greater margin of improvement.

Oral antibiotics to prevent postoperative urinary tract infection: a randomized controlled trial.

OBJECTIVE: To evaluate whether nitrofurantoin prophylaxis prevents postoperative urinary tract infection (UTI) in patients receiving transurethral catheterization after pelvic reconstructive surgery. METHODS: In a randomized, double-blind, placebo-controlled trial, participants undergoing pelvic reconstructive surgery were randomized to 100 mg nitrofurantoin or placebo once daily during catheterization if they were: 1) discharged with a transurethral Foley or performing intermittent self-catheterization; or 2) hospitalized overnight with a transurethral Foley. Our primary outcome was treatment for clinically suspected or culture-proven UTI within 3 weeks of surgery. Statistical analysis was performed by χ2 and logistic regression. Assuming 80% power at a P value of .05, 156 participants were needed to demonstrate a two-thirds reduction in UTI. RESULTS: Of 159 participants, 81 (51%) received nitrofurantoin and 78 (49%) received placebo. There were no significant differences in baseline demographics, intraoperative characteristics, duration and type of catheterization, or postoperative hospitalization, except a lower rate of hysterectomy in the nitrofurantoin group. Nitrofurantoin prophylaxis did not reduce the risk of UTI treatment within 3 weeks of surgery (22% UTI with nitrofurantoin compared with 13% UTI with placebo, relative risk 1.73, 95% confidence interval 0.85-3.52, P=.12). Urinary tract infection treatment was higher in premenopausal women, lower in diabetics, and increased with longer duration of catheterization. In logistic regression adjusting for menopause, diabetes, preoperative postvoid residual volume, creatinine clearance, hysterectomy, and duration of catheterization, there was still no difference in UTI with nitrofurantoin as compared with placebo. CONCLUSION: Prophylaxis with daily nitrofurantoin during catheterization does not reduce the risk of postoperative UTI in patients receiving short-term transurethral catheterization after pelvic reconstructive surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01450800. LEVEL OF EVIDENCE: I.

Characterizing the phenotype of advanced pelvic organ prolapse.

OBJECTIVE: Genetic studies require a clearly defined phenotype to reach valid conclusions. Our aim was to characterize the phenotype of advanced prolapse by comparing women with stage III to IV prolapse with controls without prolapse. METHODS: Based on the pelvic organ prolapse quantification examination, women with stage 0 to stage I prolapse (controls) and those with stage III to stage IV prolapse (cases) were prospectively recruited as part of a genetic epidemiologic study. Data regarding sociodemographics; medical, obstetric, and surgical history; family history; and body mass index were obtained by a questionnaire administered by a trained coordinator and abstracted from electronic medical records. RESULTS: There were 275 case patients with advanced prolapse and 206 controls with stage 0 to stage I prolapse. Based on our recruitment strategy, the women were younger than the controls (64.7 ± 10.1 vs 68.6 ± 10.4 years; P<0.001); cases were also more likely to have had one or more vaginal deliveries (96.0% vs 82.0%; P<0.001). There were no differences in race, body mass index, and constipation. Regarding family history, cases were more likely to report that either their mother and/or sister(s) had prolapse (44.8% vs 16.9%, P<0.001). In a logistic regression model, vaginal parity (odds ratio, 4.05; 95% confidence interval, 1.67-9.85) and family history of prolapse (odds ratio, 3.74; 95% confidence interval, 2.16-6.46) remained significantly associated with advanced prolapse. CONCLUSIONS: Vaginal parity and a family history of prolapse are more common in women with advanced prolapse compared to those without prolapse. These characteristics are important in phenotyping advanced prolapse, suggesting that these data should be collected in future genetic epidemiologic studies.

Trends in the surgical management of stress urinary incontinence.

OBJECTIVES: To estimate the rates of stress urinary incontinence (SUI) surgery from 2000 to 2009 by type of procedure, year, age, and region of the country. METHODS: We used data between 2000 and 2009 from a database containing health care claims data from employer-based plans in the United States. We analyzed data for all women age 18-64 years, identifying all SUI procedures in this population. Rates per 100,000 person-years and 95% confidence intervals (CI) were calculated each year by procedure type, age, and region. RESULTS: The study population included 32.9 million women age 18-64 years observed for 74,007,937 person-years between 2000 and 2009. During that time, there were 182,110 SUI procedures for a rate of 246.1 per 100,000 person-years (95% CI 239.7-252.6). The most common SUI surgery was sling (198.3 per 100,000 person-years, 95% CI 192.8-203.9) followed by Burch (25.9 per 100,000 person-years, 95% CI 24.8-27.2). There was a dramatic increase in slings, with a corresponding decrease in Burch procedures from 2000 to 2009. Other SUI surgeries had lower rates. Although this trend was evident across all regions, the Northeast had the lowest rate of SUI surgery, whereas rates in the West, Midwest, and South were 1.44-times, 1.76-times, and 2.09-times higher, respectively. CONCLUSION: In a dramatic shift over the past decade, slings have become the dominant procedure for SUI among women age 18-64 years. Although this trend was seen across the United States, considerable variability exists in the SUI surgery rates by region. LEVEL OF EVIDENCE: III.