Gluteal muscle fatty infiltration, fall risk, and mobility limitation in older women with urinary incontinence: a pilot study.

OBJECTIVE: Gluteal muscle quality influences risk of falling and mobility limitation. We sought (1) to compare gluteal muscle fatty infiltration (FI) between groups of older women with urinary incontinence (UI) at risk for falling (at-risk group) and not at risk for falling (not-at-risk group), and (2) to determine correlation of gluteal FI with Timed Up and Go (TUG) and Short Physical Performance Battery (SPPB) performance. MATERIALS AND METHODS: Prospective pilot study of gluteal FI on pelvis MRI for 19 women with UI, aged ≥ 70 years. A musculoskeletal radiologist selected axial T1-weighted MR images; then, two blinded medical student research assistants analyzed gluteal FI by quantitative fuzzy C-means segmentation. TUG and SPPB tests were performed. TUG ≥ 12 s defined participants as at risk for falling. Descriptive, correlation, and reliability analyses were performed. RESULTS: Mean age, 76.3 ± 4.8 years; no difference for age or body mass index (BMI) between the at-risk (n = 5) versus not-at-risk (n = 14) groups. SPPB score (p = 0.013) was lower for the at-risk group (6.4 ± 3.1) than for the not-at-risk group (10.2 ± 1.9). Fuzzy C-means FI-%-estimate differed between the at-risk group and the not-at-risk group for bilateral gluteus medius/minimus (33.2% ± 15.6% versus 19.5% ± 4.1%, p = 0.037) and bilateral gluteus maximus (33.6% ± 15.6% versus 19.7% ± 6.9%, p = 0.047). Fuzzy C-means FI-%-estimate for bilateral gluteus maximus had significant (p < 0.050) moderate correlation with age (rho = - 0.64), BMI (rho = 0.65), and TUG performance (rho = 0.52). Fuzzy C-means FI-%-estimates showed excellent inter-observer and intra-observer reliability (intraclass correlation coefficient, ≥ 0.892). CONCLUSION: Older women with UI at risk for falling have greater levels of gluteal FI and mobility limitation as compared to those not at risk for falling.

Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries. DATA SOURCES: PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included. METHODS: Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals. RESULTS: Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures. CONCLUSION: Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.

Physical performance measures in older women with urinary incontinence: pelvic floor disorder or geriatric syndrome?

INTRODUCTION AND HYPOTHESIS: To evaluate physical performance measures of mobility and functional impairments and assess their association with urinary incontinence (UI) severity and impact on quality of life among older women with UI. METHODS: In a cross-sectional pilot study, 20 women aged ≥ 70 years with UI completed UI questionnaires (Global Impression of Severity, Incontinence Impact Questionnaire [IIQ-7]) and functional status evaluation. Functional status evaluation included the Modified Physical Performance Test (MPPT; range 0-36), Short Physical Performance Battery (SPPB; range 0-12), and other physical performance measures (e.g., Timed Up and Go [TUG]). MPPT and SPPB scores < 32 and < 10, respectively, indicated impaired mobility and function. Descriptive statistics and Spearman correlation coefficients evaluated study variables and associations between UI and physical performance measures. RESULTS: Women were 76.6 ± 4.7 years old with mean body mass index 33.5 ± 9.0 kg/m2. Mixed UI was the most prevalent (n = 17; 85%), and 14 (70%) participants rated their UI as moderate or severe. Low MPPT (< 32) and SPPB (< 10) scores were present in 65% (n = 13) and 35% (n = 7) of participants, respectively. Lower MPPT score (r = -0.46; P = 0.04) and worse TUG performance (r = 0.50; P = 0.03) were associated with greater UI impact on quality of life based on IIQ-7. SPPB did not correlate (P > 0.05) with UI measures. CONCLUSIONS: Mobility and functional impairments are common among older women with UI. Associations between MPPT score and TUG performance with UI impact on quality of life suggest these physical performance measures could be markers of mobility and functional impairments in future research on UI in older women.

Autonomic neurophysiologic implications of disorders comorbid with bladder pain syndrome vs myofascial pelvic pain.

AIMS: The neuropathophysiology of a debilitating chronic urologic pain condition, bladder pain syndrome (BPS), remains unknown. Our recent data suggests withdrawal of cardiovagal modulation in subjects with BPS, in contrast to sympathetic nervous system dysfunction in another chronic pelvic pain syndrome, myofascial pelvic pain (MPP). We evaluated whether comorbid disorders differentially associated with BPS vs MPP shed additional light on these autonomic differences. METHODS: We compared the presence and relative time of onset of 27 other medical conditions in women with BPS, MPP, both syndromes, and healthy subjects. Analysis included an adjustment for multiple comparisons. RESULTS: Among 107 female subjects (BPS alone = 32; BPS with MPP = 36; MPP alone = 9; healthy controls = 30), comorbidities differentially associated with BPS included irritable bowel syndrome (IBS), dyspepsia, and chronic nausea, whereas those associated with MPP included migraine headache and dyspepsia, consistent with the distinct autonomic neurophysiologic signatures of the two disorders. PTSD (earliest), anxiety, depression, migraine headache, fibromyalgia, chronic fatigue, and IBS usually preceded BPS or MPP. PTSD and the presence of both pelvic pain disorders in the same subject correlated with significantly increased comorbid burden. CONCLUSIONS: Our study suggests a distinct pattern of comorbid conditions in women with BPS. These findings further support our hypothesis of primary vagal defect in BPS as compared with primary sympathetic defect in MPP, suggesting a new model for chronic these pelvic pain syndromes. Chronologically, PTSD, migraine, dysmenorrhea, and IBS occurred early, supporting a role for PTSD or its trigger in the pathophysiology of chronic pelvic pain.

Sensory mapping of pelvic dermatomes in women with interstitial cystitis/bladder pain syndrome.

AIM: To describe a sensory map of pelvic dermatomes in women with Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS). We hypothesized that if IC/BPS involves changes in central processing, then women with IC/BPS will exhibit sensory abnormalities in neurologic pelvic dermatomes. METHODS: Women with IC/BPS and healthy controls underwent neurologic examination that included evaluation of sharp pain sensitivity and vibration in dermatomes T12, L1, L2, S1-5. Peripheral nervous system sensitivity to pressure, vibration, and pinprick were scored using numeric rating scales (NRS). Bilateral comparisons were made with Wilcoxon signed-rank test and comparisons between groups were made by the Mann-Whitney U-test. RESULTS: Total of 74 women with IC/BPS and 36 healthy counterparts were included. IC/BPS and control groups had similar age (43.0 ± 14.1 and 38.6 ± 15.3 years, P = 0.14) and BMI (28.9 ± 8.0 kg/m2 and 26.9 ± 8.4 kg/m2 , P = 0.24), respectively. Women with IC/BPS reported hyperalgesia (elevated bilateral NRS pain intensity) in all pelvic dermatomes compared to healthy controls. S4-S5 region had the highest pain intensity in all participants. All IC/BPS participants exhibited vibration sensation hypoesthesia, at least unilaterally, in all of the pelvic dermatomes except L1 compared to healthy controls. CONCLUSION: This detailed map of neurologic pelvic dermatomes in women with IC/BPS found hyperalgesia in all pelvic dermatomes, and some evidence of vibration sensation hypoesthesia, compared to healthy controls. These findings support the hypothesis that IC/BPS may involve changes in central signal processing biased towards nociception.

Pelvic floor disorders in women with gynecologic malignancies: a systematic review.

INTRODUCTION AND HYPOTHESIS: Pelvic floor disorders (PFDs) negatively affect quality of life in the general population, and their prevalence in gynecologic cancer survivors has not been systematically described. This study aimed to determine the prevalence of PFDs in cancer survivors. We hypothesized that the prevalence of PFDs in the gynecologic cancer population would be higher than in the general female population. METHODS: We searched PubMed (1809 to present), EMBASE (1974 to present), and the Cochrane Central Register of Controlled Trials (CENTRAL) through May 2017. The search combined subject headings, title, and abstract words for gynecologic cancer, PFDs, and prevalence. Any studies evaluating the prevalence of PFDs in gynecologic malignancies were included. RESULTS: A total of 550 articles met the designated search criteria and 31 articles were included in this review. In cervical cancer survivors, before treatment the prevalences of stress urinary incontinence (SUI), urgency urinary incontinence (UUI) and fecal incontinence (FI) were 24-29%, 8-18% and 6%, respectively, and after treatment the prevalences of SUI, UUI, urinary retention, FI, fecal urge, dyspareunia and vaginal dryness were 4-76%, 4-59%, 0.4-39%, 2-34%, 3-49%, 12-58% and 15-47%, respectively. In uterine cancer survivors, before treatment the prevalences of SUI, UUI and FI were 29-36%, 15-25% and 3%, respectively, and after treatment the prevalences of urinary incontinence (UI) and dyspareunia were 2-44% and 7-39%, respectively. In vulvar cancer survivors, after treatment the prevalences of UI, SUI and FI were 4-32%, 6-20% and 1-20%, respectively. In ovarian cancer survivors, the prevalences of SUI, UUI, prolapse and sexual dysfunction were 32-42%, 15-39%, 17% and 62-75%, respectively. CONCLUSIONS: PFDs are prevalent in gynecologic cancer survivors and this is an important area of clinical concern and future research.

Functional status in older women diagnosed with pelvic organ prolapse.

BACKGROUND: Functional status plays an important role in the comprehensive characterization of older adults. Functional limitations are associated with an increased risk of adverse treatment outcomes, but there are limited data on the prevalence of functional limitations in older women with pelvic floor disorders. OBJECTIVE: The aim of the study was to describe the prevalence of functional limitations based on health status in older women with pelvic organ prolapse (POP). STUDY DESIGN: This pooled, cross-sectional study utilized data from the linked Health and Retirement Study and Medicare files from 1992 through 2008. The analysis included 890 women age ≥65 years with POP. We assessed self-reported functional status, categorized in strength, upper and lower body mobility, activities of daily living (ADL), and instrumental ADL (IADL) domains. Functional limitations were evaluated and stratified by respondents self-reported general health status. Descriptive statistics were used to compare categorical and continuous variables, and logistic regression was used to measure differences in the odds of functional limitation by increasing age. RESULTS: The prevalence of functional limitations was 76.2% in strength, 44.9% in upper and 65.8% in lower body mobility, 4.5% in ADL, and 13.6% in IADL. Limitations were more prevalent in women with poor or fair health status than in women with good health status, including 91.5% vs 69.9% in strength, 72.9% vs 33.5% in upper and 88.0% vs 56.8% in lower body mobility, 11.6% vs 0.9% in ADL, and 30.6% vs 6.7% in IADL; all P < .01. The odds of all functional limitations also increased significantly with advancing age. CONCLUSION: Functional limitations, especially in strength and body mobility domains, are highly prevalent in older women with POP, particularly in those with poor or fair self-reported health status. Future research is necessary to evaluate if functional status affects clinical outcomes in pelvic reconstructive and gynecologic surgery and whether it should be routinely assessed in clinical decision-making when treating older women with POP.

Multidisciplinary approach for management of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome and rectal prolapse.

INTRODUCTION AND HYPOTHESIS: Müllerian duct anomalies are frequently associated with congenital anomalies of other organ systems, and in particular, the urinary system. A multidisciplinary approach is often required for successful diagnosis and surgical management of complex pelvic anomalies. The objective of this video is to provide a guide for diagnosis of complex female pelvic anomalies and robotic-assisted approach to surgical management with a multidisciplinary team of surgeons. METHODS: The patient presented is a 24-year-old nulligravida with obstructed hemivagina and ipsilateral renal dysplasia, ipsilateral ectopic ureter, and rectal prolapse. This video outlines the methods used to obtain the correct diagnosis and steps for successful treatment using a robotically assisted surgical approach. RESULTS: Complex Müllerian anomalies involving multiple organ systems may require the use of advanced three-dimensional imaging to achieve the correct diagnosis, and a minimally invasive surgical approach with robotic assistance is an effective strategy for management. CONCLUSIONS: A multidisciplinary approach is often required to successfully diagnose and treat women with complex Müllerian anomalies.

Vaginal estrogen use in postmenopausal women with pelvic floor disorders: systematic review and practice guidelines.

INTRODUCTION AND HYPOTHESIS: Risk of pelvic floor disorders increases after menopause and may be linked to estrogen deficiency. We aimed to systematically and critically assess the literature on vaginal estrogen in the management of pelvic floor disorders in postmenopausal women and provide evidence-based clinical practice guidelines. METHODS: MEDLINE and Cochrane databases were searched from inception to July 2014 for randomized controlled trials of commercially available vaginal estrogen products compared with placebo, no treatment, or any medication for overactive bladder or urinary incontinence. We double-screened 1,805 abstracts and identified 12 eligible papers. Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality and strength of evidence. RESULTS: Evidence was generally of poor to moderate quality. Vaginal estrogen application before pelvic organ prolapse surgery improved the vaginal maturation index and increased vaginal epithelial thickness. Postoperative vaginal estrogen use after a midurethral sling resulted in decreased urinary frequency and urgency. Vaginal estrogen and immediate-release oxybutynin were similar in improvement of urinary urgency, frequency, and urgency urinary incontinence in women with overactive bladder, but oxybutynin had higher rates of side effects and discontinuation. Conversely, the addition of vaginal estrogen to immediate or extended-release tolterodine did not improve urinary symptoms more than tolterodine alone. One study reported an improvement in stress urinary incontinence with use of vaginal estrogen. CONCLUSION: Vaginal estrogen application may play a useful role as an adjunct in the management of common pelvic floor disorders in postmenopausal women.

Nonestrogen Therapies for Treatment of Genitourinary Syndrome of Menopause: A Systematic Review.

OBJECTIVE: To systematically review the literature and provide clinical practice guidelines regarding various nonestrogen therapies for treatment of genitourinary syndrome of menopause (GSM). DATA SOURCES: MEDLINE, EMBASE, ClinicalTrials.gov , and Cochrane databases were searched from inception to July 2021. We included comparative and noncomparative studies. Interventions and comparators were limited to seven products that are commercially available and currently in use (vaginal dehydroepiandrosterone [DHEA], ospemifene, laser or energy-based therapies, polycarbophil-based vaginal moisturizer, Tibolone, vaginal hyaluronic acid, testosterone). Topical estrogen, placebo, other nonestrogen products, as well as no treatment were considered as comparators. METHODS OF STUDY SELECTION: We double-screened 9,131 abstracts and identified 136 studies that met our criteria. Studies were assessed for quality and strength of evidence by the systematic review group. TABULATION, INTEGRATION, AND RESULTS: Information regarding the participants, details on the intervention and comparator and outcomes were extracted from the eligible studies. Alternative therapies were similar or superior to estrogen or placebo with minimal increase in adverse events. Dose response was noted with vaginal DHEA and testosterone. Vaginal DHEA, ospemifene, erbium and fractional carbon dioxide (CO 2 ) laser, polycarbophil-based vaginal moisturizer, tibolone, hyaluronic acid, and testosterone all improved subjective and objective signs of atrophy. Vaginal DHEA, ospemifene, tibolone, fractional CO 2 laser, polycarbophil-based vaginal moisturizer, and testosterone improved sexual function. CONCLUSION: Most nonestrogen therapies are effective treatments for the various symptoms of GSM. There are insufficient data to compare nonestrogen options to each other.

Evidence-Informed, Interdisciplinary, Multidimensional Action Plan to Advance Overactive Bladder Research and Treatment Initiatives: Directives From State-of-the-Science Conference on Overactive Bladder and Cognitive Impairment.

ABSTRACT: This article outlines an evidence-informed, interdisciplinary, multidimensional, comprehensive action plan for the American Urogynecologic Society to improve care of women with overactive bladder (OAB) while minimizing treatment-related adverse events, including cognitive impairment. It is a "call to action" to advance basic, translational, and clinical research and summarizes initiatives developed at the State-of-the-Science Conference on OAB and Cognitive Impairment to (1) develop framework for a new OAB treatment approach in women, (2) define research gaps and future research priorities, (3) champion health equity and diversity considerations in OAB treatment, (4) foster community and promote education to remove stigma surrounding OAB and urinary incontinence, and (5) elevate visibility and impact of OAB, by creating partnerships through education and engagement with health care professionals, industry, private and public payers, funding agencies, and policymakers.

Overactive Bladder and Cognitive Impairment: The American Urogynecologic Society and Pelvic Floor Disorders Research Foundation State-of-the-Science Conference Summary Report.

IMPORTANCE: Overactive bladder (OAB) is prevalent in older adults in whom management is complicated by comorbidities and greater vulnerability to the cognitive effects of antimuscarinic medications. OBJECTIVES: The aim of this study is to provide a comprehensive evidence-based summary of the 2021 State-of-the-Science (SOS) conference and a multidisciplinary expert literature review on OAB and cognitive impairment. STUDY DESIGN: The American Urogynecologic Society and the Pelvic Floor Disorders Research Foundation convened a 3-day collaborative conference. Experts from multidisciplinary fields examined cognitive function, higher neural control of the OAB patient, risk factors for cognitive impairment in older patients, cognitive effects of antimuscarinic medications for OAB treatment, OAB phenotyping, conservative and advanced OAB therapies, and the need for a multidisciplinary approach to person-centered treatment. Translational topics included the blood-brain barrier, purine metabolome, mechanotransduction, and gene therapy for OAB targets. RESULTS: Research surrounding OAB treatment efficacy in cognitively impaired individuals is limited. Short- and long-term outcomes regarding antimuscarinic effects on cognition are mixed; however, greater anticholinergic burden and duration of use influence risk. Oxybutynin is most consistently associated with negative cognitive effects in short-term, prospective studies. Although data are limited, beta-adrenergic agonists do not appear to confer the same cognitive risk. CONCLUSIONS: The 2021 SOS summary report provides a comprehensive review of the fundamental, translational, and clinical research on OAB with emphasis on cognitive impairment risks to antimuscarinic medications. Duration of use and antimuscarinic type, specifically oxybutynin when examining OAB treatments, appears to have the most cognitive impact; however, conclusions are limited by the primarily cognitively intact population studied. Given current evidence, it appears prudent to minimize anticholinergic burden by emphasizing nonantimuscarinic therapeutic regimens in the older population and/or those with cognitive impairment.

Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review.

OBJECTIVE: To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications. DATA SOURCES: PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022. METHODS OF STUDY SELECTION: The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies. TABULATION, INTEGRATION, AND RESULTS: Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy. CONCLUSION: Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021234511.

Comparison of Urinary Incontinence in Older White and Black Women: A Pilot Study.

This pilot-cross sectional study compared Urinary Incontinence symptom type and severity, and impact of UI on Quality of Life among older White and Black women. Outcome measures included a three-day bladder diary (3dbd), Incontinence Impact Questionnaire Short Form (IIQ-7), Urinary Distress Inventory Short Form (UDI-6), Medical Epidemiological Social Aspects of Ageing (MESA) questionnaire, and Patient Global Impact of Severity Scale (PGI-S). Participants' characteristics and UI outcomes were analysed with descriptive statistics, Fisher's Exact and Mann-Whitney U tests. Twenty women (10 White, and 10 Black) with mean age of 76.5 (± 4.9 years) participated in the study. There were no significant differences in most UI symptoms based on 3dbd, MESA, PGI-S, UDI-6, and IIQ-7. However, older Black women reported moderate and/or severe impact of UI on their emotional health more frequently (n=7, 70%) compared to White women (n=1, 10%, p=0.02) based on the IIQ-7.

Community-based Versus Traditional Research Among Older Minority Women With Urinary Incontinence.

OBJECTIVE: The aim of this study was to evaluate research retention of older minority women with urinary incontinence (UI) using a community-based participatory research (CBPR) versus a traditional research approach. METHODS: An ancillary prospective study was conducted within an ongoing pilot randomized clinical trial to treat UI. Participants were recruited using CBPR in collaboration with a local community versus a traditional research approach at an academic center. Inclusion criteria were women 65 years and older and symptomatic UI. The primary outcome was the randomization rate defined as the proportion of women randomized into the randomized clinical trial out of screened participants. Screening and consent rates were also evaluated. Pearson χ2, Fisher exact, and t tests were used. The effect of CBPR on research retention rates was expressed as odds ratio (OR) with 95% confidence intervals (CI). RESULTS: There were 10 and 88 women screened in the CBPR and traditional research groups, respectively. The CBPR participants were Hispanic (n = 10, 100%) and older (78.4 ± 8.3 years; P < 0.01). Most of the traditional research participants were non-Hispanic Black (n = 55, 62.5%) and younger (71.0 ± 4.9 years). The CBPR group had higher rates of screening (76.9% vs 40.6%; P = 0.01), consent (80% vs 44.3%; P = 0.045), and randomization (50.0% vs 14.8%; P < 0.01) compared with the traditional research group. Community-based participatory research increased the odds of research retention during screening (OR, 4.9; 95% CI, 1.3-18.2), consent (OR, 5.0; 95% CI, 1.0-25.0), and randomization (OR, 5.8; 95% CI, 1.5-22.7). CONCLUSION: Compared with traditional research, CBPR yielded higher research retention among older minority women with UI in a clinical study.

Preoperative hesitating urinary stream is associated with postoperative voiding dysfunction and surgical failure following Burch colposuspension or pubovaginal rectus fascial sling surgery.

INTRODUCTION AND HYPOTHESIS: We hypothesized that certain preoperative voiding symptoms would be correlated with poorer post-continence surgery outcomes in women. METHODS: Preoperative voiding symptoms from 655 women were assessed with questionnaires. Outcomes (overall failures, stress-specific failures, and voiding dysfunction) after Burch or sling surgery were measured. Logistic regression models were used to associate preoperative voiding symptoms with postoperative outcomes. RESULTS: Hesitating urinary stream was associated with voiding dysfunction [OR 2.22, p=0.01], overall [OR 1.57, p=0.03], and stress-specific [OR 1.67, p=0.009] failures. A ten-point increase in preoperative Urogenital Distress Inventory-obstructive (UDI-O) subscore was associated with overall [OR 1.10, p=0.049] and stress-specific [OR 1.21, p<0.0001] failures. Even controlling for severity of POPQ stage, significant associations of hesitating urinary stream with voiding dysfunction, overall and stress-specific failures remained. CONCLUSIONS: Preoperative hesitating urinary stream and obstructive voiding symptoms were associated with poorer surgical outcomes. Further studies in this area may be fruitful.

Changes in sexual function after treatment for prolapse are related to the improvement in body image perception.

INTRODUCTION: In a previous study, sexual function was related to a woman's self-perceived body image and degree of bother from pelvic organ prolapse (POP). AIMS: To evaluate sexual function, prolapse symptoms, and self-perceived body image 6 months following treatment for POP and to explore differences in body image perception and sexual function following conservative and surgical treatment for POP. METHODS: After institutional review board approval, consecutive women with > or = stage II POP were invited to participate. In addition to routine urogynecologic history and physical examination, including Pelvic Organ Prolapse Quantification (POP-Q), the participants completed three validated questionnaires before, and 6 months after, treatment for POP: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Modified Body Image Perception Scale and Prolapse subscale of Pelvic Floor Distress Inventory to assess condition specific bother from POP. Main Outcome Measures. Changes in sexual function and body image perception following treatment for POP. RESULTS: A total of 235 women with a mean age of 62 +/- 12 years returned for a 6-month follow-up. The majority of our participants had surgical repair for POP (88%). At 6-month follow-up visits, the patients reported significant improvement in sexual function from baseline (33 +/- 0.6 vs. 43 +/- 0.8, respectively P < 0.0001). Improvement in sexual function, as measured by PISQ-12, was not significant among sexually active patients treated with a pessary compared with those treated surgically (-2.5 +/- 5.5 vs. 11.5 +/- 1, respectively P < 0.0001). A multivariate linear regression model demonstrated that body mass index and changes in body image perception were the only independent factors associated with changes in PISQ score following POP treatment (beta = -0.5, P < 0.01 and beta = -0.4, P < 0.03, respectively). CONCLUSIONS: Resolution of POP symptoms after treatment improves women's self-perceived body image and sexual function. Not surprisingly, pessary is less effective in improving sexual function compared with surgical repair of POP.

Anatomic outcomes of abdominal sacrocolpopexy with or without paravaginal repair.

INTRODUCTION AND HYPOTHESIS: We sought to compare rates of recurrent cystocele following sacrocolpopexy with and without paravaginal repair (PVR). METHODS: This retrospective cohort study compared outcomes for patients undergoing sacrocolpopexy with (group A) and without (group B) concomitant PVR. Defining anterior failure as point Ba > or = -1 cm, we compared anatomic outcomes and reoperation rates for recurrence of cystocele. RESULTS: One hundred seventy patients undergoing sacrocolpopexy had anterior wall prolapse at or beyond the hymen before surgery (62 in group A and 108 in group B). Ten (16.1%) patients in group A and 29 (26.9%) in group B experienced anterior wall prolapse to or beyond -1 cm (p = 0.13, power 0.38). Among these groups, one (1.6%) and five (4.6%) underwent reoperation for cystocele recurrence (p=0.42, power <0.3). CONCLUSIONS: Despite the trend toward improved clinical outcomes, we were unable to detect a statistically significant difference with inclusion of PVR with sacrocolpopexy.

Risk factors leading to midurethral sling revision: a multicenter case-control study.

INTRODUCTION AND HYPOTHESIS: To determine risk factors for sling revision after midurethral sling (MUS) placement. METHODS: This multicenter case-control study included patients who underwent MUS placement and subsequent revision secondary to voiding dysfunction from January 1999-2007 from nine Urogynecology centers across the USA. Direct logistic regression analysis was used to determine which diagnostic variables predicted sling revision. RESULTS: Of the patients, 197 met the study criteria. Patient demographics, urodynamic findings, and operative differences did not increase the risk for sling revision. Risk factors for sling revision did include: pre-existing voiding symptoms (OR 2.76, 95% CI 1.32-5.79; p = 0.004) retropubic sling type (OR = 2.28, 95% CI 1.08-4.78; p = 0.04) and concurrent surgery (OR = 4.88, 95% CI 2.16-11.05; p < 0.001) CONCLUSIONS: This study determined that pre-existing obstructive voiding symptoms, retropubic sling type, and concurrent surgery at the time of sling placement are risk factors for sling revision.