Perioperative outcomes following pelvic floor reconstruction in women with hereditary disorders of connective tissue: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Women with hereditary disorders of connective tissue (HDCT) are at increased risk of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). We hypothesized that patients would have increased incidence and severity of perioperative complications up to 6 weeks after surgeries for POP/SUI. Secondary objectives were to compare pre- and post-operative pelvic floor symptoms and anatomical support as well as pelvic floor disorder recurrence. METHODS: In this multi-center retrospective cohort study, we identified patients with HDCTs by patient history and ICD-9 codes over an 11-year period. Controls without HDCTs were matched 2:1 to the primary POP or SUI procedure and surgeon. Demographic characteristics, perioperative pelvic floor information and complications were collected. A sample size of 65 HDCT patients and 130 controls was calculated to detect a 20% difference in complications with 80% power and alpha of 0.05. RESULTS: We identified 59 HDCT patients and 118 controls. Of the women with HDCTs, 49% had Ehlers-Danlos, 22% joint hypermobility syndrome, 15% Marfan syndrome, and 14% had others. Compared with controls, HDCT patients had more total perioperative complications (46% vs 22%, p = 0.002); an age-adjusted relative risk of complications was 1.4 (CI 0.7-2.6). HDCT patients had more Clavien-Dindo grades I and II complications (p = 0.02, 0.03) and more hospital readmissions (14% vs 3%, p = 0.01) than controls. There was no difference in the incidence of specific complications nor was there a difference in recurrence of POP (10%) or SUI (11%) between groups. CONCLUSIONS: Patients with HDCTs had more Clavien-Dindo grade I and II complications following pelvic floor reconstructive surgery and more readmissions.

Longitudinal changes in pelvic floor muscle strength among parous women.

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

Risk factors for explantation due to infection after sacral neuromodulation: a multicenter retrospective case-control study.

BACKGROUND: Sacral neuromodulation is an effective therapy for overactive bladder, urinary retention, and fecal incontinence. Infection after sacral neurostimulation is costly and burdensome. Determining optimal perioperative management strategies to reduce the risk of infection is important to reduce this burden. OBJECTIVE: We sought to identify risk factors associated with sacral neurostimulator infection requiring explantation, to estimate the incidence of infection requiring explantation, and identify associated microbial pathogens. STUDY DESIGN: This is a multicenter retrospective case-control study of sacral neuromodulation procedures completed from Jan. 1, 2004, through Dec. 31, 2014. We identified all sacral neuromodulation implantable pulse generator implants as well as explants due to infection at 8 participating institutions. Cases were patients who required implantable pulse generator explantation for infection during the review period. Cases were included if age ≥18 years old, follow-up data were available ≥30 days after implantable pulse generator implant, and the implant was performed at the institution performing the explant. Two controls were matched to each case. These controls were the patients who had an implantable pulse generator implanted by the same surgeon immediately preceding and immediately following the identified case who met inclusion criteria. Controls were included if age ≥18 years old, no infection after implantable pulse generator implant, follow-up data were available ≥180 days after implant, and no explant for any reason <180 days from implant. Controls may have had an explant for reasons other than infection at >180 days after implant. Fisher exact test (for categorical variables) and Student t test (for continuous variables) were used to test the strength of the association between infection and patient and surgery characteristics. Significant variables were then considered in a multivariable logistic regression model to determine risk factors independently associated with infection. RESULTS: Over a 10-year period at 8 academic institutions, 1930 sacral neuromodulator implants were performed by 17 surgeons. In all, 38 cases requiring device explant for infection and 72 corresponding controls were identified. The incidence of infection requiring explant was 1.97%. Hematoma formation (13% cases, 0% controls; P = .004) and pocket depth of ≥3 cm (21% cases, 0% controls; P = .031) were independently associated with an increased risk of infection requiring explant. On multivariable regression analysis controlling for significant variables, both hematoma formation (P = .006) and pocket depth ≥3 cm (P = .020, odds ratio 3.26; 95% confidence interval, 1.20-8.89) remained significantly associated with infection requiring explant. Of the 38 cases requiring explant, 32 had cultures collected and 24 had positive cultures. All 5 cases with a hematoma had a positive culture (100%). Of the 4 cases with a pocket depth ≥3 cm, 2 had positive cultures, 1 had negative cultures, and 1 had a missing culture result. The most common organism identified was methicillin-resistant Staphylococcus aureus (38%). CONCLUSION: Infection after sacral neuromodulation requiring device explant is low. The most common infectious pathogen identified was methicillin-resistant S aureus. Demographic and health characteristics did not predict risk of explant due to infection, however, having a postoperative hematoma or a deep pocket ≥3 cm significantly increased the risk of explant due to infection. These findings highlight the importance of meticulous hemostasis as well as ensuring the pocket depth is <3 cm at the time of device implant.

Obstetric Recommendations in American Congress of Obstetricians and Gynecologists Practice Bulletins versus UpToDate: a comparison.

OBJECTIVE: To compare the obstetric recommendations in American Congress of Obstetricians and Gynecologists (ACOG) practice bulletins (PB) with similar topics in UpToDate (UTD). STUDY DESIGN: We accessed all obstetric PB and cross-searched UTD (May 1999-May 2013). We analyzed only the PB which had corresponding UTD chapter with graded recommendations (level A-C). To assess comparability of recommendations for each obstetric topic, two maternal-fetal medicine (MFM) subspecialists categorized the statement as similar, dissimilar, or incomparable. Simple and weighted kappa statistics were calculated to assess agreement between the two raters. RESULTS: We identified 46 ACOG obstetric PB and 86 UTD chapters. There were 50% fewer recommendations in UTD than in PB (181 vs. 365). The recommendations being categorized as level A, B, or C was significantly different (p < 0.001) for the two guidelines. While the overall concordance rate between the two MFM subspecialists was 83% regarding the recommendations for the same topic as similar, dissimilar, or incomparable, the agreement was moderate (kappa, 0.56; 95% confidence intervals, 0.48-0.65). CONCLUSION: Though obstetricians have two sources for graded recommendations, incongruity among them may be a source of consternation. Congruent recommendations from ACOG and UTD could enhance compliance and potentially optimize outcomes.

Nocturnal Urinary Symptoms as Screening Tools for Obstructive Sleep Apnea.

IMPORTANCE: Nocturnal lower urinary tract symptoms are part of obstructive sleep apnea (OSA), and urogynecology clinics may serve as OSA screening sites. OBJECTIVE: This study's aim was to determine the accuracy of nocturia and nocturnal enuresis (NE) as screening tools for OSA in new patients at a urogynecology clinic. STUDY DESIGN: Using a retrospective study design, we gathered information regarding diagnostic OSA testing, continuous positive airflow pressure use, and lower urinary tract symptoms improvement from women in a urogynecology clinic who were previously screened for OSA using validated questionnaires. Nocturia and NE were tested for sensitivity and specificity using positive OSA diagnosis by polysomnography as the gold standard. RESULTS: Nocturia with a cutoff of ≥2 episodes per night had the best test characteristics-86.4% sensitivity (95% confidence interval [CI], 65.1-97.1) and 58.5% specificity (95% CI, 44.1-71.9) for an overall accuracy of 78.4% (95% CI, 67.0-89.8). Nocturnal enuresis with a cutoff of ≥1 episode per week had the best NE characteristics with 31.8% sensitivity (95% CI, 13.9-54.9) and 79.3% specificity (95% CI, 65.9-89.2) for an overall accuracy of 56.1% (95% CI, 41.2-71). CONCLUSIONS: Lower urinary tract symptoms such as nocturia and NE are routinely assessed in urogynecology clinics, making them useful for OSA screening and referral. The present study found nocturia symptoms with ≥2 episodes per night to retain acceptable test characteristics in screening for OSA, whereas NE was found to have less acceptable test characteristics for OSA screening. Urogynecology clinics may utilize nocturia symptoms in clinical decision making for OSA referral.

Function and disability status among women with fistula using WHODAS2.0: A descriptive study from Rwanda and Democratic Republic of Congo.

OBJECTIVE: To assess function and disability among women in Rwanda and Democratic Republic of Congo living with fistula and identify characteristics associated with higher disability scores. METHODS: Women presenting for fistula care were recruited. Eligible participants underwent a physical examination to classify fistula type and completed the WHO Disability Assessment Schedule 2.0 questionnaire to ascertain the impact of fistula on function across six domains: cognition, mobility, self-care, getting along, life activities, and participation. Disability scores were calculated (where 0 = no disability and 100 = complete disability). Participants were grouped according to no, low, or high disability status; results were examined to determine the domains most affected. RESULTS: Among 69 participants, fistula type included: vesicovaginal (59.4%), ureterovaginal (14.5%), total absence of proximal urethra (11.6%), and rectovaginal (14.5%). Median disability score was 43.0/100 (interquartile range 26.0-67.0); 83% exhibited high disability status. Life activities and participation in society domains were most affected. Women with rectovaginal fistula reported the lowest scores, and those with total absence of proximal urethra reported the highest scores. CONCLUSION: WHO Disability Assessment Schedule 2.0 represents a simple, robust measure of global disability status, aligns with research efforts to estimate maternal disability, and may inform health needs and resource allocation for this population. In this study, disability was common, varied by fistula type, and affected physical, mental, and social domains.

Prevalence of Screening High Risk of Obstructive Sleep Apnea Among Urogynecology Patients.

OBJECTIVES: There is limited knowledge on the prevalence of obstructive sleep apnea (OSA) among urogynecology patients. The aim of this study was to determine the prevalence of screening high risk of OSA (HR-OSA) in an ambulatory urogynecology clinic. METHODS: Women presenting for a new patient visit to a single outpatient urogynecology clinic for any indication were screened for eligibility. Patients were included if they were 18 years or older, English speaking, nonpregnant, and not using treatment for OSA. Participants completed the STOP-BANG questionnaire to screen for OSA and additional questionnaires to assess the presence and classification of nocturia and urinary incontinence. RESULTS: Among 130 participants, the prevalence of screening HR-OSA was 38.5%. Characteristics associated with screening HR-OSA included hypertension (P < 0.001), diabetes (P=0.003), untreated sleep apnea (P < 0.001), body mass index ≥30 kg/m (P < 0.001), and age >50 years (P < 0.001). Participants who screened HR-OSA were more likely to have bothersome bladder symptoms of nocturia (P < 0.001), nocturnal enuresis (P < 0.001), higher urinary distress inventory scores (P < 0.001), and incontinence severity index scores (P < 0.001). On multivariable analysis, age >50 years (odds ratio [OR], 7.54), hypertension (OR, 4.04), body mass index ≥30 kg/m (OR, 3.98), and nocturial enuresis (OR, 2.26) remained significantly associated with screening HR-OSA. Average time to complete the STOP-BANG was 1.2 minutes. CONCLUSIONS: The prevalence of OSA among urogynecology patients is high, and screening is not time prohibitive. Patients who screen HR-OSA have more bothersome bladder symptoms. Providers should consider screening urogynecology patients for OSA, especially patients who are 50 years or older, are obese, and have nocturnal enuresis.