Patient perspectives on treatment and prevention of recurrent urinary tract infections: a focus group study.

INTRODUCTION AND HYPOTHESIS: We sought to understand factors that are important to patients for the management of recurrent urinary tract infections (UTI) during both an acute episode and for the prevention of future episodes. METHODS: This was a qualitative study with focus groups in women with recurrent UTIs. Participants filled out information about prior recurrent UTI treatment and the Belief about Medicines Questionnaire (BMQ). Each 90-minute focus group was moderated by a nonphysician psychologist. Line-by-line coding of each transcript by three independent physicians was used to develop emergent concepts and themes using Grounded Theory methodology. RESULTS: Twenty-six women participated in six focus groups. The average age of participants was 62 years and 77% were post-menopausal. All women had already tried multiple prevention strategies for their recurrent UTIs. The average BMQ-specific scores indicated a net positive attitude toward medicines specifically prescribed for recurrent UTI prevention. Several themes emerged from the focus groups. First, patients wanted providers to acknowledge the high burden imposed by frequent interactions with the health care system for the management of recurrent UTI. Second, patients wanted earlier access to providers knowledgeable in the management of this condition. Third, patients wanted to self-manage their condition through a structured treatment plan with support from their providers. Finally, patients wanted greater emphasis on education and prevention strategies to reduce their antibiotic intake. CONCLUSIONS: Patients with recurrent UTI want more efficient workflows, a framework that promotes self-management in partnership with their providers, and a greater emphasis on prevention.

Dietary Intake and Symptom Severity in Women with Fecal Incontinence.

INTRODUCTION AND HYPOTHESIS: The goal of this study was to determine whether dietary fat/fiber intake was associated with fecal incontinence (FI) severity. METHODS: Planned supplemental analysis of a randomized clinical trial evaluating the impact of 12-week treatment with percutaneous tibial nerve stimulation versus sham in reducing FI severity in women. All subjects completed a food screener questionnaire at baseline. FI severity was measured using the seven-item validated St. Mark's (Vaizey) FI severity scale. Participants also completed a 7-day bowel diary capturing the number of FI-free days, FI events, and bowel movements per week. Spearman's correlations were calculated between dietary, St. Mark's score, and bowel diary measures. RESULTS: One hundred and eighty-six women were included in this analysis. Mean calories from fats were 32% (interquartile range [IQR] 30-35%). Mean dietary fiber intake was 13.9 ± 4.3 g. The percentage of calories from fats was at the higher end of recommended values, whereas fiber intake was lower than recommended for adult women (recommended values: calories from fat 20-35% and 22-28 g of fiber/day). There was no correlation between St. Mark's score and fat intake (r = 0.11, p = 0.14) or dietary fiber intake (r = -0.01, p = 0.90). There was a weak negative correlation between the number of FI-free days and total fat intake (r = -0.20, p = 0.008). Other correlations between dietary fat/fiber intake and bowel diary measures were negligible or nonsignificant. CONCLUSION: Overall, in women with moderate to severe FI, there was no association between FI severity and dietary fat/fiber intake. Weak associations between FI frequency and fat intake may suggest a role for dietary assessment in the evaluation of women with FI.

Development of a patient-centered text message-based platform for the self-management of interstitial cystitis/bladder pain syndrome symptoms.

OBJECTIVE: To develop a patient-centered text message-based platform that promotes self-management of symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS). METHODS: Adult women with IC/BPS interested in initiating a first- or second-line treatments per American Urological Association guidelines (recategorized as "behavioral/non-pharmacologic treatments" and "oral medicines" in the 2022 version) participated in rapid cycle innovation consisting of iterative cycles of contextual inquiry, prototype design and development. We delivered treatment modules and supportive messages using an algorithm-driven interactive messaging prototype through a HIPAA-compliant texting platform. Patients provided feedback through narrative text messages and an exit interview. Feedback was analyzed qualitatively and used to iteratively revise the platform until engagement ≥ 85% and accuracy ≥ 80% were achieved. The final version consisted of four treatment module categories (patient education and behavioral modification, cognitive behavioral therapy, pelvic floor physical therapy, and guided mindfulness practices) and supportive messages delivered through an automated algorithm over 6 weeks. RESULTS: Thirty IC/BPS patients with moderate symptom bother (median IC Problem Index score 9, range 6-12) participated in five cycles of contextual inquiry. Qualitative analysis identified three overarching concepts that informed the development of the platform: preference for patient centered terms, desire to gain self-efficacy in managing symptoms, and need for provider support. Patients preferred the term "interstitial cystitis" to "bladder pain syndrome" which carried the stigma of chronic pain. Patients reported greater self-efficacy in managing symptoms through improved access to mind-body and behavioral treatment modules that helped them to gain insight into their motivations and behaviors. The concept of provider support was informed by shared decision making (patients could choose preferred treatment modules) and reduced sense of isolation (weekly check in messages to check on symptom bother). CONCLUSION: A patient centered text message-based platform may be clinically useful in the self-management of IC/BPS symptoms.

"Every minute counts": association between operative time and post-operative complications for patients undergoing minimally invasive sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Our aim was to assess whether operative time is independently associated with post-operative complications for minimally invasive sacrocolpopexy (MISCP). METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database, patients undergoing MISCP from 2015 to 2020 were identified by CPT code. The following data were extracted: demographics, concomitant procedures (hysterectomies, midurethral sling, and anterior or posterior repair), and post-operative complications. Complications were categorized into minor, major, and composite, modeled after the Clavien-Dindo classification. For analysis, covariates associated with operative time and composite complications were identified using a general linear model and Chi-squared or Fisher's exact test as appropriate. Then, adjusted spline regression was performed as a test of nonlinearity between operative time and composite complications. Adjusted relative risks of complications by 60-min increments were estimated using Poisson regression with robust error variance. RESULTS: A total of 13,239 patients who underwent MISCP were analyzed. Overall, mean operative time (SD) was 189.5 (78.3) min. Post-operative complication rates were 2.6% for minor, 4.7% for major, and 7.3% for composite complications. Age, smoking, and sling were the only covariates associated with both operative time and post-operative complications. Adjusted spline regression demonstrated linearity (p<0.0001). With each 60-min increase in operative time, adjusted relative risks (95% CI) were 1.14 for composite (1.09, 1.19), 1.16 for minor (1.10, 1.21), and 1.11 (1.03, 1.20) for major complications. CONCLUSIONS: Operative time is independently and linearly associated with post-operative complications for patients undergoing MISCP, even when adjusted for demographic variables and concomitant procedures.

Impact of Surgical Wait Time to Hysterectomy for Benign Gynecologic Disease.

STUDY OBJECTIVE: To determine the impact of surgical wait time on healthcare use and surgical outcomes for patients undergoing hysterectomy for benign gynecologic indications. DESIGN: Retrospective cohort study. SETTING: Urban, academic tertiary care center. PATIENTS: Patients who underwent hysterectomy for benign disease between 2012 and 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were categorized into 2 groups, dichotomized by surgical wait times >30 days or ≤30 days. Healthcare use was measured by the number of discrete patient interactions with the healthcare system through phone calls, secure electronic messaging, and office and emergency room visits. Univariate and multivariable logistic regression models were performed to assess the association between surgical wait time and healthcare use and perioperative outcomes while controlling for confounders. A total of 277 patients were included in our analysis: 106 (38.3%) had surgical wait times >30 days (median 47 days, range 24-68 days), and 171 (67.1%) had surgical wait times ≤30 days (median 19 days; range 12-26 days). The groups did not differ by age, insurance status, substance use, or comorbid conditions. Patients in the group with surgical wait times >30 days were more likely to have increased healthcare use (69 of 106, 65% vs 43 of 171, 25%; odds ratio 5.55; 95% confidence interval, 3.27-9.41). There were no differences in intraoperative complications (9 of 106, 8% vs 19 of 171, 11%; p = .482) or postoperative complications (28 of 106, 26% vs 32 of 171, 19%; p = .13) between the groups; however, after controlling for potential confounders, patients with surgical wait times >30 days were 3.22 times more likely to be readmitted than patients with surgical wait times ≤30 days (95% confidence interval, 1.27-8.19). CONCLUSION: A surgical wait time >30 days in patients undergoing a hysterectomy for benign disease is associated with increased healthcare use in the interim. Although patients who experience longer surgical wait times do not experience worse surgical outcomes, they may be at higher risk for readmission after surgery. Targeted interventions to optimize perioperative coordination of care for patients undergoing a hysterectomy for benign disease, especially those within vulnerable populations, are needed to improve quality of care, decrease any redundant or inefficient healthcare use, and reduce any unnecessary delays.

Association between adjuvant posterior repair and success of native tissue apical suspension.

BACKGROUND: Posterior repairs and perineorrhaphies are often performed in prolapse surgery to reduce the size of the genital hiatus. The benefit of an adjuvant posterior repair at the time of sacrospinous ligament fixation or uterosacral ligament suspension is unknown. OBJECTIVE: We aimed to determine whether an adjuvant posterior repair at transvaginal apical suspension is associated with improved surgical success. MATERIALS AND METHODS: This secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial compared 24-month outcomes in 190 participants who had a posterior repair (posterior repair group) and 184 who did not (no posterior repair group) at the time of sacrospinous ligament fixation or uterosacral ligament suspension. Concomitant posterior repair was performed at the surgeon's discretion. Primary composite outcome of "surgical success" was defined as no prolapse beyond the hymen, point C ≤ -2/3 total vaginal length, no bothersome bulge symptoms, and no retreatment at 24 months. The individual components were secondary outcomes. Propensity score methods were used to build models that balanced posterior repair group and the no posterior repair group for ethnographic factors and preoperative Pelvic Organ Prolapse Quantification values. Adjusted odds ratios were calculated to predict surgical success based on the performance of a posterior repair. Groups were also compared with unadjusted χ2 analyses. An unadjusted probability curve was created for surgical success as predicted by preoperative genital hiatus. RESULTS: Women in the posterior repair group were less likely to be Hispanic or Latina, and were more likely to have had a prior hysterectomy and to be on estrogen therapy. The groups did not differ with respect to preoperative Pelvic Organ Prolapse Quantification stage; however, subjects in the posterior repair group had significantly greater preoperative posterior wall prolapse. There were no group differences in surgical success using propensity score methods (66.7% posterior repair vs 62.0% no posterior repair; adjusted odds ratio, 1.07; 95% confidence interval, 0.56-2.07; P = 0.83) or unadjusted test (66.2% posterior repair vs 61.7% no posterior repair; P = 0.47). Individual outcome measures of prolapse recurrence (bothersome bulge symptoms, prolapse beyond the hymen, or retreatment for prolapse) also did not differ by group. Similarly, there were no differences between groups in anatomic outcomes of any individual compartment (anterior, apical, or posterior) at 24 months. There was high variation in performance of posterior repair by surgeon (interquartile range, 15-79%). The unadjusted probability of overall success at 24 months, regardless of posterior repair, decreased with increasing genital hiatus, such that a genital hiatus of 4.5 cm was associated with 65.8% success (95% confidence interval, 60.1-71.1%). CONCLUSION: Concomitant posterior repair at sacrospinous ligament fixation or uterosacral ligament suspension was not associated with surgical success after adjusting for baseline covariates using propensity scores or unadjusted comparison. Posterior repair may not compensate for the pathophysiology that leads to enlarged preoperative genital hiatus, which remains prognostic of prolapse recurrence.

Impact of treatment for fecal incontinence on constipation symptoms.

OBJECTIVE: Defecatory symptoms, such as a sense of incomplete emptying and straining with bowel movements, are paradoxically present in women with fecal incontinence. Treatments for fecal incontinence, such as loperamide and biofeedback, can worsen or improve defecatory symptoms, respectively. The primary aim of this study was to compare changes in constipation symptoms in women undergoing treatment for fecal incontinence with education only, loperamide, anal muscle exercises with biofeedback or both loperamide and biofeedback. Our secondary aim was to compare changes in constipation symptoms among responders and nonresponders to fecal incontinence treatment. STUDY DESIGN: This was a planned secondary analysis of a randomized controlled trial comparing 2 first-line therapies for fecal incontinence in a 2 × 2 factorial design. Women with at least monthly fecal incontinence and normal stool consistency were randomized to 4 groups: (1) oral placebo plus education only, (2) oral loperamide plus education only, (3) placebo plus anorectal manometry-assisted biofeedback, and (4) loperamide plus biofeedback. Defecatory symptoms were measured using the Patient Assessment of Constipation Symptoms questionnaire at baseline, 12 weeks, and 24 weeks. The Patient Assessment of Constipation Symptoms consists of 12 items that contribute to a global score and 3 subscales: stool characteristics/symptoms (hardness of stool, size of stool, straining, inability to pass stool), rectal symptoms (burning, pain, bleeding, incomplete bowel movement), and abdominal symptoms (discomfort, pain, bloating, cramps). Scores for each subscale as well as the global score range from 0 (no symptoms) to 4 (maximum score), with negative change scores representing improvement in defecatory symptoms. Responders to fecal incontinence treatment were defined as women with a minimally important clinical improvement of ≥5 points on the St Mark's (Vaizey) scale between baseline and 24 weeks. Intent-to-treat analysis was performed using a longitudinal mixed model, controlling for baseline scores, to estimate changes in Patient Assessment of Constipation Symptoms scores from baseline through 24 weeks. RESULTS: At 24 weeks, there were small changes in Patient Assessment of Constipation Symptoms global scores in all 4 groups: oral placebo plus education (-0.3; 95% confidence interval, -0.5 to -0.1), loperamide plus education (-0.1, 95% confidence interval, -0.3 to0.0), oral placebo plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2), and loperamide plus biofeedback (-0.3, 95% confidence interval, -0.4 to -0.2). No differences were observed in change in Patient Assessment of Constipation Symptoms scores between women randomized to placebo plus education and those randomized to loperamide plus education (P = .17) or placebo plus biofeedback (P = .82). Change in Patient Assessment of Constipation Symptoms scores in women randomized to combination loperamide plus biofeedback therapy was not different from that of women randomized to treatment with loperamide or biofeedback alone. Responders had greater improvement in Patient Assessment of Constipation Symptoms scores than nonresponders (-0.4; 95% confidence interval, -0.5 to -0.3 vs -0.2; 95% confidence interval, -0.3 to -0.0, P < .01, mean difference, 0.2, 95% confidence interval, 0.1-0.4). CONCLUSION: Change in constipation symptoms following treatment of fecal incontinence in women are small and are not significantly different between groups. Loperamide treatment for fecal incontinence does not worsen constipation symptoms among women with normal consistency stool. Women with clinically significant improvement in fecal incontinence symptoms report greater improvement in constipation symptoms.

Regions of the brain activated in bladder filling vs rectal distention in healthy adults: A meta-analysis of neuroimaging studies.

AIMS: Adults with pelvic floor disorders commonly present with overlapping bladder and bowel symptoms; however, the relationship between urinary and defecatory dysfunction is not well understood. Our aim was to compare and determine if overlapping brain regions are activated during bladder filling and rectal distention in healthy adults. METHODS: We conducted separate Pubmed searches for neuroimaging studies investigating the effects of rectal distention and bladder filling on brain activation in healthy subjects. Coordinates of activated regions were extracted with cluster-level threshold P < .05 and compared using the activation likelihood estimate approach. Results from the various studies were pooled and a contrast analysis was performed to identify any common areas of activation between bladder filling and rectal distension. RESULTS: We identified 96 foci of activation from 14 neuroimaging studies on bladder filling and 182 foci from 17 studies on rectal distension in healthy adults. Regions activated during bladder filling included right insula, right and left thalamus, and right periaqueductal grey. Regions activated during rectal distention included right and left insula, right and left thalamus, left postcentral gyrus, and right inferior parietal lobule. Contrast analysis revealed common activation of the right insula with both rectal distention and bladder filling. CONCLUSION: Bladder filling and rectal distention activate several separate areas of the brain involved in sensory processing in healthy adults. The common activation of the insula, the region responsible for interoception, in these two conditions may offer an explanation for the coexistence of bladder and defecatory symptoms in pelvic floor disorders.

Perioperative adverse events in women over age 65 undergoing robot-assisted sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Pelvic floor disorders are common among and disproportionately affect older women. There are limited data regarding perioperative adverse events in older women undergoing robot-assisted sacrocolpopexy (RASC) specifically. The aim of this study was to compare the rate of perioperative adverse events in younger (age <65 years) versus older (age >65 years) women who underwent RASC. METHODS: We conducted a retrospective cohort study of women who underwent RASC between 2013 and 2018. Postoperative adverse events were categorized according to the Clavien-Dindo classification. Our primary outcome was the rate of intraoperative adverse events and postoperative adverse events with Clavien-Dindo grade II or greater. Outcomes were compared using univariate and multivariate analysis. RESULTS: Of the 327 patients included in the study, 227 were <65 years of age and 100 were ≥65 years of age. Women ≥65 years of age had higher rates of hypertension, higher American Society of Anesthesiologist (ASA) class, and higher Charlson Comorbidity Index (CCI) scores compared with women <65 years of age; these were not associated with increased likelihood of adverse events. The overall rate of any perioperative adverse event was 18.3%. There was no statistically significant difference in the overall rate of perioperative adverse events between younger and older women (18.5% vs 18.0%, p = 0.91). CONCLUSIONS: There is no difference in rate of adverse events between women ≥65 years of age undergoing RASC and their younger counterparts.

Sacral neuromodulation versus onabotulinumtoxinA for refractory urgency urinary incontinence: impact on fecal incontinence symptoms and sexual function.

BACKGROUND: Women with refractory urgency urinary incontinence can be treated with onabotulinumtoxinA or sacral neuromodulation. Little data exists on the comparative effects of treatment of refractory urgency urinary incontinence on other pelvic floor complaints, such as bowel and sexual function. OBJECTIVE: The objective of this study was to compare the impact of these treatments on fecal incontinence and sexual symptoms. METHODS: This was a planned supplemental analysis of a randomized trial in women with refractory urgency urinary incontinence treated with onabotulinumtoxinA (n = 190) or sacral neuromodulation (n = 174). Fecal incontinence and sexual symptoms were assessed at baseline and at 6, 12, and 24 months. Fecal incontinence symptoms were measured using the St Mark's (Vaizey) Fecal Incontinence severity scale. Sexual symptoms were measured using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) and the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). The PISQ-IR allows measurement of sexual symptoms in both sexually active and non-sexually active adults. Primary outcomes were change in Vaizey and PISQ-12 scores between baseline and 6 months. Secondary outcomes were change in PISQ-IR total and subscores between baseline and 6 months and change in Vaizey, PISQ-12, and PISQ-IR scores between baseline and 12 and 24 months. Intent-to-treat analysis was performed using repeated measures mixed model to estimate change in all parameters from baseline while adjusting for the baseline score. A subgroup analysis of women with clinically significant bowel symptoms was conducted based on baseline Vaizey score of ≥12. RESULTS: At baseline, mean Vaizey scores were indicative of mild fecal incontinence symptoms and were not different between onabotulinumtoxinA and sacral neuromodulation groups (7.6 ± 5.3 vs 6.6 ± 4.9, P = .07). The proportion of sexually active women (56% vs 63%, P = .25), mean PISQ-12 score (33.4 ± 7.5 vs 32.7 ± 6.7, P = .55), or PISQ-IR subscores were also not different between the onabotulinumtoxinA and sacral neuromodulation groups at baseline. There was no difference between women treated with onabotulinumtoxinA and those treated with sacral neuromodulation at 6 months in terms of improvement in fecal incontinence symptom score (Vaizey: -1.9, 95% confidence interval -2.6 to -1.2 vs -0.9, 95% confidence interval -1.7 to -0.2, P = .07) or sexual symptoms score (PISQ-12: 2.2, 95% confidence interval 0.7 to 3.7 vs 2.2, 95% confidence interval 0.7 to 3.7, P = .99). There was no difference in improvement between groups in the sexual symptom subscores in sexually active and non-sexually active women at 6 months. Similar findings were noted at 12 and 24 months. In a subgroup (onabotulinumtoxinA = 33 and sacral neuromodulation = 22) with clinically significant fecal incontinence at baseline (Vaizey score ≥12), there was a clinically meaningful improvement in symptoms in both groups from baseline to 6 months, with no difference in improvement between the onabotulinumtoxinA and sacral neuromodulation groups (-5.1, 95% confidence interval -7.3 to -2.8 vs -5.6, 95% confidence interval -8.5 to -2.6, P = .8). CONCLUSION: There were no differences in improvement of fecal incontinence and sexual symptoms in women with urgency urinary incontinence treated with onabotulinumtoxinA or sacral neuromodulation. Women with significant fecal incontinence symptoms at baseline had clinically important improvement in symptoms, with no difference between the treatments. Our findings can help clinicians counseling women considering treatment for refractory urgency urinary incontinence.

Gaining the patient perspective on pelvic floor disorders' surgical adverse events.

BACKGROUND: The Institute for Healthcare Improvement defines an adverse event as an unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization or that results in death. The majority of research has focused on adverse events from the provider's perspective. OBJECTIVE: The objective of this qualitative study was to describe patient perceptions on adverse events following surgery for pelvic floor disorders. STUDY DESIGN: Women representing the following 3 separate surgical populations participated in focus groups: (1) preoperative (women <12 weeks prior to surgery); (2) short-term postoperative (women up to 12 weeks after surgery); and (3) long-term postoperative (women 1-5 years after surgery). Deidentified transcripts of audio recordings were coded and analyzed with NVivo 10 software to identify themes, concepts, and adverse events. Women were asked to rank patient-identified and surgeon-identified adverse events in order of perceived severity. RESULTS: Eighty-one women participated in 12 focus groups. Group demographics were similar between groups, and all groups shared similar perspectives regarding surgical expectations. Women commonly reported an unclear understanding of their surgery and categorized adverse events such as incontinence, constipation, nocturia, and lack of improvement in sexual function as very severe, ranking these comparably with intensive care unit admissions or other major surgical complications. Women also expressed a sense of personal failure and shame if symptoms recurred. CONCLUSION: Women consider functional outcomes such as incontinence, sexual dysfunction, and recurrence of symptoms as severe adverse events and rate them as similar in severity to intensive care unit admissions and death.

Feasibility and outcomes: Pilot Randomized Controlled Trial of a home-based integrated physical exercise and bladder-training program vs usual care for community-dwelling older women with urinary incontinence.

AIMS: To assess the feasibility of a randomized controlled trial of a home-based integrated physical exercise and bladder-training program vs usual care in community-dwelling women with urinary incontinence (UI). METHODS: We conducted a parallel arm, nonblinded, pilot randomized controlled trial of a home-based integrated physical exercise and bladder training with urge suppression and fall prevention program (ExerciseUP) vs usual care in women aged 65 and older with UI. Outcomes included feasibility (process, resources, management, and acceptability), urinary symptoms, and falls risk using self-administered questionnaires. Objective physical activity was measured using accelerometry. RESULTS: A total of 37 of 38 (97%) eligible women were willing to participate in the study. In the ExerciseUP intervention cohort, 17 of 19 (89%) women completed all 6 weeks of intervention and follow-up, and 16 of 18 (89%) women in the usual group completed follow-up. Ten (53%) women in the ExerciseUP group achieved at least 70% adherence to exercise prescription. The improvement in UI severity scores from baseline was greater in the ExerciseUP intervention group than the usual care group (- 6.2 ± 5.8 vs - 2.4 ± 4.2, P = 0.04). Fall-risk score decreased (improved) in both groups. There were no significant between-group differences in change in physical activity or sedentary behavior. CONCLUSIONS: We determined that it would be feasible to conduct a home-based exercise intervention in older women with UI. Our clinical outcomes were modestly favorable for the ExerciseUP intervention group.

Validity of utility measures for women with pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse is a common condition that frequently coexists with urinary and fecal incontinence. The impact of prolapse on quality of life is typically measured through condition-specific quality-of-life instruments. Utility preference scores are a standardized generic health-related quality-of-life measure that summarizes morbidity on a scale from 0 (death) to 1 (optimum health). Utility preference scores quantify disease severity and burden and are widely used in cost-effectiveness research. The validity of utility preference instruments in women with pelvic organ prolapse has not been established. OBJECTIVE: The objective of this study was to evaluate the construct validity of generic quality-of-life instruments for measuring utility scores in women with pelvic organ prolapse. Our hypothesis was that women with multiple pelvic floor disorders would have worse (lower) utility scores than women with pelvic organ prolapse only and that women with all 3 pelvic floor disorders would have the worst (lowest) utility scores. STUDY DESIGN: This was a prospective observational study of 286 women with pelvic floor disorders from a referral female pelvic medicine and reconstructive surgery practice. All women completed the following general health-related quality-of-life questionnaires: Health Utilities Index Mark 3, EuroQol, and Short Form 6D, as well as a visual analog scale. Pelvic floor symptom severity and condition-specific quality of life were measured using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire, respectively. We measured the relationship between utility scores and condition-specific quality-of-life scores and compared utility scores among 4 groups of women: (1) pelvic organ prolapse only, (2) pelvic organ prolapse and stress urinary incontinence, (3) pelvic organ prolapse and urgency urinary incontinence, and (4) pelvic organ prolapse, urinary incontinence, and fecal incontinence. RESULTS: Of 286 women enrolled, 191 (67%) had pelvic organ prolapse; mean age was 59 years and 73% were Caucasian. Among women with prolapse, 30 (16%) also had stress urinary incontinence, 39 (20%) had urgency urinary incontinence, and 42 (22%) had fecal incontinence. For the Health Utilities Index Mark 3, EuroQol, and Short Form 6D, the pattern in utility scores was noted to be lowest (worst) in the prolapse + urinary incontinence + fecal incontinence group (0.73-0.76), followed by the prolapse + urgency urinary incontinence group (0.77-0.85) and utility scores were the highest (best) for the prolapse only group (0.80-0.86). Utility scores from all generic instruments except the visual analog scale were significantly correlated with the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire total scores (r values -0.26 to -0.57), and prolapse, bladder, and bowel subscales (r values -0.16 to -0.50). Utility scores from all instruments except the visual analog scale were highly correlated with each other (r = 0.53-0.69, P < .0001). CONCLUSION: The Health Utilities Index Mark 3, EuroQol, and Short Form 6D, but not the visual analog scale, provide valid measurements for utility scores in women with pelvic organ prolapse and associated pelvic floor disorders and could potentially be used for cost-effectiveness research.

Refractory urgency urinary incontinence treatment in women: impact of age on outcomes and complications.

BACKGROUND: Women with refractory urgency urinary incontinence (ie, unresponsive to behavioral and pharmacological interventions) are treated with onabotulinumtoxinA or sacral neuromodulation. OBJECTIVE: The objective of the study was to compare treatment efficacy and adverse events in women <65 and ≥65 years old treated with onabotulinumtoxinA or sacral neuromodulation. STUDY DESIGN: This study was a planned secondary analysis of a multicenter, randomized trial that enrolled community-dwelling women with refractory urgency urinary incontinence to onabotulinumtoxinA or sacral neuromodulation treatments. The primary outcome was a change in mean daily urgency urinary incontinence episodes on a bladder diary over 6 months. Secondary outcomes included ≥75% urgency urinary incontinence episode reduction, change in symptom severity/quality of life, treatment satisfaction, and treatment-related adverse events. RESULTS: Both age groups experienced improvement in mean urgency urinary incontinence episodes per day following each treatment. There was no evidence that mean daily urgency urinary incontinence episode reduction differed between age groups for onabotulinumtoxinA (adjusted coefficient, -0.127, 95% confidence interval, -1.233 to 0.979; P = .821) or sacral neuromodulation (adjusted coefficient, -0.698, 95% confidence interval, -1.832 to 0.437; P = .227). Among those treated with onabotulinumtoxinA, women <65 years had 3.3-fold greater odds of ≥75% resolution than women ≥65 years (95% confidence interval, 1.56 -7.02). Women <65 years had a greater reduction in Overactive Bladder Questionnaire Short Form symptom bother scores compared with women ≥65 years by 7.49 points (95% confidence interval, -3.23 to -11.74), regardless of treatment group. There was no difference between quality of life improvement by age. Women ≥65 years had more urinary tract infections following onabotulinumtoxinA and sacral neuromodulation (odds ratio, 1.9, 95% confidence interval, 1.2-3.3). There was no evidence of age differences in sacral neuromodulation revision/removal or catheterization following onabotulinumtoxinA treatment. CONCLUSION: Younger women experienced greater absolute continence, symptom improvement, and fewer urinary tract infections; both older and younger women had beneficial urgency urinary incontinence episode reduction, similar rates of other treatment adverse events, and improved quality of life.

The relationship between fecal incontinence, constipation and defecatory symptoms in women with pelvic floor disorders.

AIMS: To determine if fecal incontinence (FI) is associated with constipation and defecatory symptoms in women with urinary incontinence, fecal incontinence, and pelvic organ prolapse. METHODS: Cross-sectional study of women seeking care for urinary incontinence, fecal incontinence, and pelvic organ prolapse. FI was defined as a positive response to the question, "During the last 4 weeks how often have you leaked or soiled yourself with stool?" Constipation and defecatory symptoms, including straining, sensation of incomplete emptying, and splinting, were measured using the Birmingham Bowel Symptom Questionnaire and the Colorectal Anal Distress Inventory. Prevalence and severity of constipation and defecatory symptoms were compared between women with and without FI. We performed separate multivariable regression analyses for the association of FI and constipation and defecatory symptoms while adjusting for potential confounders. RESULTS: We included 1,015 women: 422 (44%) with and 593 (56%) without FI. Women with FI compared to those without FI were more likely to report constipation (76% vs. 66%) as well as straining (53% vs. 38%), sensation of incomplete emptying (58% vs. 40%) and splinting (30% vs. 20%), all P < 0.001. Women with FI reported greater severity of constipation (4.3 ± 4.3 vs. 3.1 ± 3.6, P < 0.001), straining (2.7 ± 1 vs. 2.5 ± 0.9, P = 0.02) and sense of incomplete emptying (2.6 ± 1 vs. 2.4 ± 0.9, P = 0.02) than women without FI. Even after controlling for potential confounders, the diagnosis of FI was significantly associated with constipation and defecatory symptoms. CONCLUSIONS: In women with urinary incontinence, fecal incontinence, and pelvic organ prolapse, diagnosis of FI is associated with constipation and other defecatory symptoms; which impacts evaluation and management strategies. Neurourol. Urodynam. 36:495-498, 2017. © 2016 Wiley Periodicals, Inc.

Clinical anatomy of fecal incontinence in women.

Fecal incontinence is a devastating condition that has a severe impact on quality of life. This condition disproportionately affects women and its incidence is increasing with the aging United States population. Fecal continence is maintained by coordination of a functioning anal sphincter complex, intact sensation of the anorectum, rectal compliance, and the ability to consciously control defecation. Particularly important are the puborectalis sling of the levator ani muscle complex and intact innervation of the central and peripheral nervous systems. An understanding of the intricate anatomy required to maintain continence and regulate defecation will help clinicians to provide appropriate medical and surgical management and diminish the negative impact of fecal incontinence. In this article, we describe the anatomic and neural basis of fecal continence and normal defecation as well as changes that occur with fecal incontinence in women. Clin. Anat. 30:901-911, 2017. © 2017 Wiley Periodicals, Inc.

Noctural Enuresis as a Risk Factor for Falls in Older Community Dwelling Women with Urinary Incontinence.

PURPOSE: We determined the association of urinary symptoms with fall risk and physical limitations in older community dwelling women with urinary incontinence. MATERIALS AND METHODS: We performed an in-depth assessment of daytime and nighttime urinary symptoms, fall risk, physical function, physical performance tests and mental function in older community dwelling women with urinary incontinence who had not sought care for urinary symptoms. All assessments were performed in participant homes. We used univariable and multivariable linear regression to examine the relationship of urinary symptoms to fall risk, physical function and physical performance. RESULTS: Of 37 women with a mean ± SD age of 74 ± 8.4 years who had urinary incontinence 48% were at high risk for falls. Nocturnal enuresis was reported by 50% of the women. Increased fall risk was associated with increasing frequency of nocturnal enuresis (p = 0.04), worse lower limb function (p <0.001), worse upper limb function (p <0.0001) and worse performance on a composite physical performance test of strength, gait and balance (p = 0.02). Women with nocturnal enuresis had significantly lower physical performance test scores than women without nocturnal enuresis (median 7, range 0 to 11 vs 9, range 1 to 12, p = 0.04). In a multivariable regression model including age, nocturnal enuresis episodes and physical function only physical function was associated with an increased fall risk (p <0.0001). CONCLUSIONS: Nocturnal enuresis is common in older community dwelling women with urinary incontinence. It may serve as a marker of fall risk even in women who do not seek care for urinary symptoms. Interventions targeting upper and lower body physical function could potentially decrease the risk of falls in older women with urinary incontinence.

Is self-reported adherence associated with clinical outcomes in women treated with anticholinergic medication for overactive bladder?

AIM: To determine the association between self-reported adherence to anticholinergic medication and clinical outcomes in women with overactive bladder (OAB). METHODS: A prospective study of women with OAB treated with fesoterodine for 8 weeks. Adherence to medication was measured using the Medication Adherence Self-report Inventory (MASRI). A self reported adherence rate of ≥80% was considered adherent. The association between self-reported adherence and clinical outcomes (Global Index of Improvement, Global impression of Severity, urinary symptom and quality of life scores) was examined. We hypothesized that adherent women would have greater improvement in urinary symptoms and quality of life than non-adherent women. RESULTS: Based on the MASRI, 115 (62.5%) women were adherent and 69 (37.5%) were non-adherent to anticholinergic medication at 8weeks. Adherent women were more likely to report overall improvement in their symptoms compared to non-adherent women (84% vs. 24%, P < 0.001). Significantly more non-adherent women described their bladder symptoms as "moderate" or "severe" at 8 weeks compared to adherent women (74% vs. 44%, P = 0.03). At 8 weeks, adherent women reported significantly greater improvement (change) in urinary symptoms from baseline to 8 weeks than non-adherent women (-13.3 ± 25.8 vs. 2.5 ± 14.4, P = 0.04). Similarly, adherent women reported greater improvement in quality of life scores than non-adherent women (- 7.9 ± 24.0 vs. -1.8 ± 11.9, P = 0.003). CONCLUSION: Self-reported non-adherence, as measured by the MASRI, is associated with clinically meaningful outcomes in women with OAB. This further validates the MASRI as a clinically useful tool for measuring adherence to anticholinergic medications in women with OAB. Neurourol. Urodynam. 35:738-742, 2016. © 2015 Wiley Periodicals, Inc.

Role of diet in fecal incontinence: a systematic review of the literature.

INTRODUCTION AND HYPOTHESIS: The objective was to perform a systematic review of the literature to examine original research on the role of diet in fecal incontinence (FI) with a dual focus on dietary differences in FI and dietary treatments for FI. METHODS: We searched the PubMed and Embase databases for any peer-reviewed original research in English on the role of diet in FI. RESULTS: We identified 172 unique citations. After title review and exclusion of articles not reporting original research, 9 publications were included in the final review: 4 focused on dietary differences and 5 focused on dietary treatments for FI. Limited evidence indicates that macro- and micronutrient intake does not differ significantly in those with and without FI. However, certain foods were perceived to improve or exacerbate FI symptoms and these varied and were adjusted as part of self-care practices. A high-fiber diet may reduce incontinence frequency. CONCLUSIONS: Data on the pathogenesis of FI from a dietary perspective are scant. Based on the limited data, dietary differences between those with and without FI provide little insight with the exception of fiber. Further studies are needed to elucidate treatments for FI using fiber and dietary modifications.

Management of arterial and venous hemorrhage during sacrospinous ligament fixation: cases and review of the literature.

INTRODUCTION AND HYPOTHESIS: Sacrospinous ligament fixation (SSLF) for pelvic organ prolapse repair can incur significant intraoperative hemorrhage. Management of vascular injury is challenging because of limited visualization of the surrounding pararectal space and is not well described in the literature. METHODS: We evaluate cases of intraoperative venous and arterial hemorrhage during SSLF. Based on a review of the literature, we present a systematic approach to the treatment of venous and arterial hemorrhage associated with SSLF. RESULTS: Vascular injury to the hypogastric and pudendal venous plexi may be controlled using directed compression and topical hemostatic agents. Vascular injury to the inferior gluteal artery, its coccygeal branch, or other arteries, may require embolization. CONCLUSION: Life-threatening bleeding is a rare complication of transvaginal SSLF. Knowledge of surrounding pelvic vascular anatomy, treatment options, and communication with ancillary staff is essential for the treatment of sacrospinous ligament hemorrhage.