Rates of colpopexy and colporrhaphy at the time of hysterectomy for prolapse.

BACKGROUND: It has been shown that addressing apical support at the time of hysterectomy for pelvic organ prolapse (POP) reduces recurrence and reoperation rates. In fact, national guidelines consider hysterectomy alone to be inadequate treatment for POP. Despite this, anterior and posterior colporrhaphy are frequently performed without a colpopexy procedure and hysterectomy alone is often utilized for treatment of prolapse. OBJECTIVE: The objectives of this study were to: (1) determine rates of concomitant procedures for POP in hysterectomies performed with POP as an indication, (2) identify factors associated with performance of a colpopexy at the time of hysterectomy for POP, and (3) identify the influence of surgical complexity on perioperative complication rates. STUDY DESIGN: This is a retrospective cohort study of hysterectomies performed for POP from Jan. 1, 2013, through May 7, 2014, in a statewide surgical quality database. Patients were stratified based on procedures performed: hysterectomy alone, hysterectomy with colporrhaphy and without apical suspension, and hysterectomy with colpopexy with or without colporrhaphy. Demographics, medical history and intraoperative care, and perioperative care were compared between the groups. Multivariable logistic regression models were created to identify factors independently associated with use of colpopexy and factors associated with increased rates of postoperative complications. RESULTS: POP was an indication in 1557 hysterectomies. Most hysterectomies were vaginal (59.6%), followed by laparoscopic or robotic (34.1%), and abdominal (6.2%). Hysterectomy alone was performed in 43.1% (95% confidence interval [CI], 40.6-45.6) of cases, 32.8% (95% CI, 30.4-35.1) had a colporrhaphy without colpopexy, and 24.1% (95% CI, 22-26.3) had a colpopexy with or without colporrhaphy. Use of colpopexy was independently associated with patient age >40 years, POP as the only indication for surgery (odd ratio [OR], 1.6; 95% CI, 1.185-2.230), laparoscopic surgery (OR, 3.2; 95% CI, 2.860-5.153), and a surgeon specializing in urogynecology (OR, 8.2; 95% CI, 5.156-12.923). The overall perioperative complication rate was 6.6%, with the majority being considered minor. Complications were more likely when the procedure was performed with an abdominal approach (OR, 2.3; 95% CI, 1.088-4.686), with the use of a colpopexy procedure (OR, 3.1; 95% CI, 1.840-5.194), and by a surgeon specializing in urogynecology (OR, 2.2; 95% CI, 1.144-4.315). CONCLUSION: Colpopexy and colporrhaphy may be underutilized and are potential targets for quality improvement. Performance of additional procedures at the time of hysterectomy increased the rate of perioperative complications. Long-term consequences of these surgical practices deserve additional study.

Histopathologic assessment of the entire endometrium in asymptomatic women.

Knowledge on the nature of the endometrium in women without symptoms of endometrial disease is poor. Therefore, the aim of this prospective study was to describe the endometrium of a cohort of asymptomatic women. The entire endometrium of premenopausal and postmenopausal women was embedded for histologic examination. All included patients underwent a hysterectomy on indication of uterovaginal prolapse, from July 2011 to October 2012, in 3 hospitals in the South of the Netherlands. Exclusion criteria were symptoms of postmenopausal vaginal blood loss or premenopausal disordered vaginal bleeding. As a result, 68 women were included in the study, 48 women were postmenopausal and 20 were premenopausal. In the endometrium of 10 women, simple hyperplasia was found (15%); 1, complex hyperplasia (2%); 2, simple atypical hyperplasia (3%); 2, complex atypical hyperplasia (3%); and 2, a small focus of intramucosal endometrioid endometrial carcinoma (3%). In general, the endometrium was heterogeneous, and most lesions were not present in the entire endometrium. In conclusion, after examining the entire endometrium, a remarkable high prevalence of endometrial pathology was found in asymptomatic women. The clinical meaning of these lesions is not yet clear, but endometrial pathology may frequently exist without symptoms.

Effects of reproductive morbidity on women's lives and costs of accessing treatment in Yemen.

Research on the consequences of reproductive morbidity for women's lives and their economic and social roles is relatively under-developed. There is also a lack of consensus on appropriate conceptual frameworks to understand the social determinants of reproductive morbidity as well as their social and economic implications. We report here on an exploratory study in Yemen using quantitative (n=72 women) and qualitative methods (n=35 women), in 2005 and 2007 respectively, with women suffering from uterine prolapse, infertility or pelvic inflammatory disease (PID). It explored women's views on how reproductive morbidity affected their lives, marital security and their households, and the burden of paying for treatment. We also interviewed six health professionals about women's health care-seeking for these conditions. Sixty per cent of women reported that treatment was not affordable, and 43% had to sell assets or take out a loan to pay for care. Prolapse and PID interfered particularly in subsistence and household activities while infertility created social pressure. Reproductive morbidity is not a priority in Yemen, given its multiple public health needs and low resources, but by failing to provide comprehensive and affordable services for women, the country incurs developmental losses.

Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth.

To compare pelvic anatomy, using magnetic resonance imaging, between postpartum women with or without pelvic floor disorders. We measured postpartum bony and soft tissue pelvic dimensions in 246 primiparas, 6-12-months postpartum. Anatomy was compared between women with and without urinary or fecal incontinence, or pelvic organ prolapse; P < 0.01 was considered statistically significant. A deeper sacral hollow was significantly associated with fecal incontinence (P = 0.005). Urinary incontinence was marginally associated with a wider intertuberous diameter (P = 0.017) and pelvic arch (P = 0.017). There were no significant differences in pelvimetry measures between women with and without prolapse (e.g., vaginal or cervical descent to or beyond the hymen). We did not detect meaningful differences in soft tissue dimensions for women with and without these pelvic floor disorders. Dimensions of the bony pelvis do not differ substantially between primiparous women with and without postpartum urinary incontinence, fecal incontinence and prolapse.

Pelvic organ prolapse in rural Ghana.

OBJECTIVE: To determine the prevalence of pelvic organ prolapse (POP) and its impact on the lives of women in Sekyidumasi, a rural Ghanaian community. METHODS: A cross-sectional study of 200 women was performed using a questionnaire and pelvic examination to detect symptoms and signs of prolapse. Main outcome measures were the presence of POP and its impact on quality of life. RESULTS: Out of 174 women included in the study, 21 women (12.07%) had POP. Seventeen of these women (81%) were symptomatic, of which only 6 women (35.3%) had sought treatment because of financial constraints. The odds of prolapse increased with increasing parity (P=0.02) and age (P<0.01). The main impacts of prolapse were on emotional well-being (52.4%), the women's relationship with their partner (46.2%), and sex life (25%). CONCLUSION: Only about one-third of women with symptomatic prolapse sought treatment because the cost of medical care outweighed the impact of the condition on their lives.

Incidence of recurrent pelvic organ prolapse 10 years following primary surgical management: a retrospective cohort study.

We conducted this study to estimate the rate of, and identify risk factors for, recurrent pelvic organ prolapse (POP) following primary surgical repair. The study consisted of a retrospective cohort study of 142 women who underwent primary surgical management of POP in 1993 and were followed up to 10 years. Prolapse severity was graded using an established classification system of clinical descriptors. Hazard ratios (HR) for recurrent POP were determined using Cox regression. 36 recurrent cases were identified (recurrence rate: 3.7 per 100 woman-years). A cystocele was the most frequent element of primary (87%) and recurrent (72%) prolapse. No predictors of the likelihood of recurrence were identified, though recurrence was somewhat more common among women with a history of two or fewer vaginal deliveries vs three or more (HR = 1.6; 95% confidence interval = 0.81-3.3). Recurrent POP following surgical management is common. Our ability to predict recurrence is limited.

Effect of body mass index on the risk of anal incontinence and defecatory dysfunction in women.

OBJECTIVE: The primary objective was to estimate the effect of body mass index on the risk of anal incontinence and defecatory dysfunction in a tertiary referral urogynecologic population. STUDY DESIGN: This was a cross-sectional study, including 519 new patients. Exposure was defined as body mass index. The primary outcome was any reported anal incontinence. The secondary outcome was any defecatory dysfunction. We used multiple logistic regression to estimate odds ratios and 95% confidence intervals for the effect of body mass index on anal incontinence and defecatory dysfunction. RESULTS: After adjusting for confounders, every 5 unit increase in body mass index was associated with a significantly increased odds of anal incontinence (odds ratio 1.25; 95% confidence interval, 1.09 to 1.44) and a trend toward an increased odds of defecatory dysfunction (odds ratio 1.13; 95% confidence interval, 0.98 to 1.31), although this was not statistically significant. CONCLUSION: Increasing body mass index is significantly associated with anal incontinence, but not defecatory dysfunction in women.

Variations in stress incontinence and prolapse management by surgeon specialty.

PURPOSE: Numerous studies have documented a relationship between provider specialty and outcomes for surgical procedures. In this study we sought to determine the effect of surgeon specialty on outcomes of sling surgery for women with stress urinary incontinence. MATERIALS AND METHODS: We analyzed the 1999 to 2001 Medicare claims data from a 5% national random sample of Medicare beneficiaries. Women 65 years or older who underwent a sling procedure between July 1, 1999 and December 31, 2000 were identified on the basis of CPT-4 codes and tracked for 12 months. Key complications were identified using CPT-4 and ICD-9 revision codes for relevant procedures and diagnoses. Outcomes were compared between urologists and gynecologists. RESULTS: A total of 1,356 sling procedures were performed. Of them 1,063 (78.4%) were performed by urologists, while 246 (18.1%) were performed by gynecologists. Urologists performed concomitant prolapse repairs in 29.1% of cases, and gynecologists performed prolapse repairs in 55.7% (p <0.0001). In the 12 months following sling surgery, urologists were more likely than gynecologists to perform a repeat incontinence procedure (9.3% vs 4.9%, p = 0.024) and prolapse repair (26.0% vs 12.2%, p <0.0001). The 2 surgical specialties did not differ in postoperative outlet obstruction, urological complications, or nonurological complications. CONCLUSIONS: Early prolapse management by gynecologists corresponded to fewer prolapse repairs in the year following the sling. Our findings suggest that gynecologists are more likely to identify and manage prolapse at the time of the evaluation of urinary incontinence, a strategy that appears to avoid the morbidity and cost of repeat surgery.

Prevalence of severe pelvic organ prolapse in relation to job description and socioeconomic status: a multicenter cross-sectional study.

The aim of this study was to determine if certain occupations or socioeconomic levels are associated with pelvic organ prolapse. Investigators at six American sites performed pelvic organ prolapse quantification examinations on women presenting for routine gynecologic care. Between September 1999 and March 2002, 1,004 patients were examined. Severe pelvic organ prolapse was defined as the leading edge being 1 cm or more beyond the hymeneal ring. The data was analyzed with the Kruskal-Wallis analysis of variance, Bonferroni test, multiple logistic regression, and descriptive statistics. The prevalence of severe pelvic organ prolapse in our group was 4.3%. Women who were laborers/factory workers had significantly more severe prolapse than the other job categories (p < 0.001). Women with annual income of Dollars 10,000 or less had significantly more severe pelvic organ prolapse than other income groups (p < 0.001). These differences persisted even when controlling for age, race, number of deliveries, body mass index >30, and smoking status (all p < 0.001). Laborers/factory worker jobs and an annual household income of Dollars 10,000 or less are associated with severe pelvic organ prolapse.

Incidence and management of abdominal sacrocolpopexy mesh erosions.

OBJECTIVE: This study was undertaken to evaluate the occurrence and management of mesh erosions in patients undergoing abdominal sacrocolpopexy. STUDY DESIGN: A retrospective chart review of the abdominal sacrocolpopexy procedure (n = 92) between 1997 and 2003 was performed. Patients with mesh erosion were identified. Incidence by graft type and treatment required for erosion resolution was analyzed with chi 2 and Fisher exact test. RESULTS: Erosions occurred in 7.6 % (7/92). Erosions were identified only in patients with Gore-Tex (3/33, 9%) or silicone-coated mesh (4/21, 19%) compared with none of 38 patients with polypropylene mesh (n = 24) or fascia (n = 14) grafts ( P = .068.). Partial excision of exposed graft resolved all 3 Gore-Tex erosions, compared with none of the silicone-coated mesh erosions ( P = .03). Complete graft removal was required to resolve silicone-coated mesh erosions. CONCLUSION: We observed a high rate of erosion with Gore-Tex and silicone-coated mesh. Partial graft excision was adequate for Gore-Tex erosions, but complete graft removal was necessary to resolve erosions associated with silicone-coated mesh.

Influence of spontaneous and instrumental vaginal delivery on objective measures of pelvic organ support: assessment with the pelvic organ prolapse quantification (POPQ) technique and functional cine magnetic resonance imaging.

OBJECTIVE: To determine the influence of spontaneous and instrumented vaginal delivery on objective measures of pelvic organ support. STUDY DESIGN: Prospective study at a university hospital with two study groups: vaginal spontaneous delivery (n = 26) and vacuum extraction (n = 49). Control group consisted of healthy nulliparous volunteers (n = 20). Participants underwent pelvic organ support evaluation by use of the pelvic organ prolapse quantification (POPQ) examination and postpartum functional cine magnetic resonance imaging (MRI). RESULTS: Significant differences for individual POPQ component measurements were noted for points Aa and Ba, TVL, and GH (spontaneous delivery versus control) and in addition for Ap, Bp, and D (vacuum extraction versus control). Significant differences for MRI measurements were observed for the position of bladder base, bladder neck, posterior fornix of the vagina, anorectal junction, hiatus perimeter and depth of rectocele. CONCLUSIONS: Considerable changes in pelvic organ support after vaginal delivery can be demonstrated by a reproducible and reliable clinical classification system (POPQ) and by functional cine magnetic resonance imaging.

Procedures for pelvic organ prolapse in the United States, 1979-1997.

OBJECTIVE: The objective of our study was to describe national rates of surgery for pelvic organ prolapse. STUDY DESIGN: We used the National Hospital Discharge Survey, a federal database that samples inpatient hospitals in the United States. Data from 1979 to 1997 were analyzed for diagnoses and procedures coded with the ICD-9-CM classification system. Age-adjusted rates were calculated by using the 1990 census population and compared for change over time by using the Score test for linear trend. RESULTS: Approximately 200,000 women undergo inpatient procedures for prolapse in the United States each year, ranging from 165,000 in 1988 to 226,000 in 1979. There was a significant decrease in the overall age-adjusted rate of procedures performed over the study period, from 2.2 to 1.5 procedures per 1000 women (P =.01). The rate of prolapse procedures for women younger than 50 years decreased by more than half (1.9 to 0.8 per 1000 women, P <.001), whereas the rate remained stable in women who were aged 50 years and older (2.7 to 3.3 per 1000 women, P =.5). CONCLUSION: Prolapse procedures are performed very frequently in the United States, although the rate has decreased slightly over time.

The demographics of pelvic floor disorders: current observations and future projections.

OBJECTIVE: Our aim was to assess current demand for care of pelvic floor disorders and create projections for future demand for care. We also sought to better understand the characteristics of women seeking care. STUDY DESIGN: Current demand for care was calculated by comparing those women seeking care through the female pelvic floor disorders clinic with those women of the same age range at risk within an integrated health care delivery program. Patients underwent complete urogynecologic evaluation including cystometry. Women seeking care were compared with regard to age, distribution of conditions (pelvic organ prolapse, stress conditions, urge conditions), and probability of undergoing surgery. Modeling the study population by use of data from the US Census Bureau, which projects population changes over the next 30 years, created predictions of future demand. RESULTS: Data were available on 2070 consecutive patients with an age range of 30 to 89 years normally distributed around a median age of 61.5 years drawn from an at-risk population of 149,000 women aged 30 to 89 years. Older women generated more consults per 1000 woman years than did the younger cohorts (1.7 vs 18.6 consults per 1000 woman years for those 30-39 years old vs those 70-79 years old; P <.05). Estimates of growth in demand at 30 years indicate a 45% increase in demand while net growth of the same population segment should be 22%. Stress conditions were more common among younger women and urge conditions were more common among older women. Pelvic organ prolapse was equally distributed throughout the age ranges. CONCLUSIONS: Over the next 30 years, growth in demand for services to care for female pelvic floor disorders will increase at twice the rate of growth of the same population. Demand for care for pelvic floor disorders comes from a wide age range of women, although mature age groups generate 10 times the number of consults per 1000 woman years as do their younger counterparts. Age plays a major role in the distribution of conditions with which patients present. These findings have broad implications for those responsible for administering programs to care for women, allocating research funds in women's health and geriatrics, and training physicians to meet this rapidly escalating demand.