A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation.

BACKGROUND: Many patients with fecal incontinence report coexisting constipation. This subset of patients has not been well characterized or understood. OBJECTIVE: The purpose of this study was to report the frequency of fecal incontinence with concurrent constipation and to compare quality-of-life outcomes of patients with fecal incontinence with and without constipation. DESIGN: This was a prospective cohort study. Survey data, including Fecal Incontinence Severity Index, Constipation Severity Instrument, Fecal Incontinence Quality of Life survey (categorized as lifestyle, coping, depression, and embarrassment), Pelvic Organ Prolapse Inventory and Urinary Distress Inventory surveys, and anorectal physiology testing were obtained. SETTINGS: The study was conducted as a single-institution study from January 2007 to January 2017. PATIENTS: Study patients had fecal incontinence presented to a tertiary pelvic floor center. MAIN OUTCOME MEASURES: Quality-of-life survey findings were measured. RESULTS: A total of 946 patients with fecal incontinence were identified, and 656 (69.3%) had coexisting constipation. Patients with fecal incontinence with constipation were less likely to report a history of pregnancy (89.2% vs 91.4%; p = 0.001) or complicated delivery, such as requiring instrumentation (9.1% vs 18.1%; p = 0.005), when compared with patients with isolated fecal incontinence. Patients with fecal incontinence with constipation had higher rates of coexisting pelvic organ prolapse (Pelvic Organ Prolapse Inventory: 18.4 vs 8.2; p < 0.01), higher rates of urinary incontinence (Urinary Distress Inventory: 30.2 vs 23.4; p = 0.01), and higher pressure findings on manometry; intussusception on defecography was common. Patients with fecal incontinence with concurrent constipation had less severe incontinence scores at presentation (21.0 vs 23.8; p < 0.001) and yet lower overall health satisfaction (28.9% vs 42.5%; p < 0.001). Quality-of-life scores declined as constipation severity increased for lifestyle, coping, depression, and embarrassment. LIMITATIONS: This was a single-institution study, and surgeon preference could bias population and anorectal physiology testing. CONCLUSIONS: Patients with fecal incontinence with concurrent constipation represent a different disease phenotype and have different clinical and anorectal physiology test findings and worse overall quality of life. Treatment of these patients requires careful consideration of prolapse pathology with coordinated treatment of coexisting disorders. See Video Abstract at http://links.lww.com/DCR/A783.

Impact of Rising Grades of Internal Rectal Intussusception on Fecal Continence and Symptoms of Constipation.

BACKGROUND: A theory of rectal intussusception has been advanced that intrarectal intussusception, intra-anal intussusception, and external rectal prolapse are points on a continuum and are a cause of fecal incontinence and constipation. OBJECTIVE: This study evaluates the association among rectal intussusception, constipation, fecal incontinence, and anorectal manometry. DESIGN: Patients undergoing defecography were studied from a prospectively maintained database and classified according to the Oxford Rectal Prolapse Grade as normal or having intra-rectal, intra-anal, or external intussusception. Patient symptoms were assessed using the Constipation Severity Index and the Fecal Incontinence Severity Index. Quality-of-life surveys were also used. Patients also underwent anorectal manometry. SETTINGS: The study was conducted at a tertiary care university medical center (Massachusetts General Hospital). PATIENTS: The study included 147 consecutive patients undergoing evaluation for evacuatory dysfunction and involved defecography, symptoms questionnaires, and anorectal physiology testing from January 2011 to December 2013. MAIN OUTCOME MEASURES: Symptom severity and quality-of-life scores were measured, as well as anal manometry results. RESULTS: Increasing Oxford grade was associated with an increase in severity of fecal incontinence (median score: normal = 23.9, intrarectal = 21.0, intra-anal = 30.0, external prolapse = 35.3; ß = 4.71; p = 0.009), which persisted in a multivariable model including age (ß = 2.13; p = 0.03), and decreased sphincter pressures (median mean resting pressure: normal = 75.4, intra-rectal = 69.7, intra-anal = 64.3, external prolapse = 48.3; ß = -8.57; p = 0.003), which did not persist in a multivariable model. Constipation severity did not increase with rising intussusception (mean score: normal = 37.4, intrarectal = 35.0, intra-anal = 41.4, external prolapse = 32.9; p = 0.79), and balloon expulsion improved rather than worsened (normal = 47.1%, intrarectal = 60.5%, intra-anal = 82.9%, external prolapse = 93.1%; p < 0.001). LIMITATIONS: The study was limited because it was an observational study from a single center. CONCLUSIONS: Increasing grades of rectal intussusception are associated with increasing fecal incontinence but not constipation.

Clinical application of IUGA/ICS classification system for mesh erosion.

AIMS: Our aim was to assess the usability of the IUGA/ICS classification system for mesh erosion in a tertiary clinical practice and to determine if assigned classification is associated with patient symptoms, treatment, and outcome. METHODS: We retrospectively identified women who had mesh erosion after prolapse or incontinence surgery. Each erosion was classified using the IUGA/ICS category time site (CTS) system. Associations between classification and presenting symptom (asymptomatic, pain, bleeding, voiding, or defecatory dysfunction, infection, prolapse), treatment type, and outcome were evaluated with chi-squared test, student's t-test, and univariate logistic regression. RESULTS: We identified 74 subjects with mesh erosion; only 70% were classifiable. Asymptomatic patients (n = 19) (Category A) were more likely to be managed conservatively (P = 0.001). Symptomatic patients (n = 55) (Category B) were more likely to be managed surgically (P = 0.003). Other variables had no association with treatment. No variables were associated with outcome. Presenting symptom was associated with both treatment (P = 0.005) and outcome (P = 0.03). Asymptomatic subjects were more likely to have satisfactory outcome (P = 0.03). Urinary frequency and urgency were highly correlated with surgical management (P = 0.02). CONCLUSIONS: One third of mesh erosions could not be retrospectively coded using the IUGA/ICS classification. The components of the system were not predictive of treatment nor outcome with exception of the Category A (asymptomatic) and Category B (symptomatic). Asymptomatic women with mesh erosion can be successfully managed with conservative measures. Use of a classification system may be enhanced if the system is simplified by limiting the number of variables to those associated with interventions and patient outcome. Neurourol. Urodynam. 35:589-594, 2016. © 2015 Wiley Periodicals, Inc.

Effect of Coexisting Pelvic Floor Disorders on Fecal Incontinence Quality of Life Scores: A Prospective, Survey-Based Study.

BACKGROUND: The association between an objective measure of fecal incontinence severity and patient-reported quality of life is poorly understood. OBJECTIVE: The purpose of this study was to evaluate patients with various degrees of fecal incontinence to determine whether their quality of life as measured by the Fecal Incontinence Quality of Life Scale is affected by coexisting pelvic floor disorders. DESIGN: This was a prospective, survey-based study. SETTINGS: The study was conducted at a tertiary pelvic floor disorders center. PATIENTS: Included patients were all of those presenting between January 2007 and March 2014. MAIN OUTCOME MEASURES: Survey data were analyzed to determine the association between Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life Scale, as well as scores from the Constipation Severity Instrument, Pelvic Floor Impact Questionnaire, Pelvic Organ Distress Inventory, and Urinary Distress Inventory. RESULTS: A total of 585 patients reported fecal incontinence ranging from none (n = 191) to mild/moderate (n = 159) to severe (n = 235). As expected, patients with severe fecal incontinence have worse scores on all fecal incontinence quality-of-life subscales (lifestyle, coping/behavior, depression/self-perception, and embarrassment) and worse colorectal/anal symptoms than those with mild/moderate or no fecal incontinence (p < 0.0001). Patients with severe fecal incontinence also have worse bladder/urinary symptoms (p ≤ 0.0001). Pelvic organ prolapse and constipation symptoms were similar between groups (p ≥ 0.61). After correcting for baseline differences in patient comorbidities and bladder/urinary symptoms, a significant association persisted between Fecal Incontinence Severity Index and all of the subscales of the fecal incontinence quality-of-life instrument (p < 0.0001). However, urinary distress scores also remained significantly associated with all of the fecal incontinence quality-of-life subscales except for embarrassment after risk adjustment (p < 0.01). LIMITATIONS: Nongeneral population and a lack of patient data on previous medical management of fecal incontinence were limitations of this study. CONCLUSIONS: The Fecal Incontinence Quality of Life Scale correlates strongly with instruments measuring both fecal and urinary incontinence. This underscores the importance of quantifying the presence or absence of coexistent urinary leakage in studies where a drop in fecal incontinence quality of life is considered a primary end point.

Low back pain does not improve with surgical treatment of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Our goal was to determine if there is a correlation between low back pain (LBP) and pelvic organ prolapse (POP) by assessing for change in LBP after surgical correction of prolapse. METHODS: Patients undergoing POP surgery were recruited to participate. They completed the Oswestry Disability Index (ODI), a validated back pain questionnaire, at their preoperative and postoperative visits at 1, 3, and 6 months. A higher ODI score (0-100) represents more severe disability. A 9-point change represents a minimal clinically important difference (MCID). The primary outcome was the change in ODI scores from preoperative to 3 months postoperative. We analyzed ODI scores with repeated measures analysis of variance (ANOVA). Power analysis showed that a sample size of 50 was needed for 88 % power to resolve a MCID on ODI. RESULTS: A total of 51 patients were recruited and 43 (84 %), 34 (67 %), and 36 (71 %) completed the 1-, 3-, and 6-month follow-up, respectively. The mean ODI scores at the preoperative and the 1-, 3-, and 6-month postoperative visits were 15, 19, 9, and 9. The mean ODI score from preoperative to 3 months postoperative improved by 5 points [confidence interval (CI) -9.2 to -0.5, p = 0.03]. Of the participants 7 (20.6 %, CI 11-35 %) experienced a MCID improvement, 24 (70.6 %, CI 56-83 %) reported no substantial change, and 3 (8.8 %, CI 3-20 %) experienced a MCID worsening. CONCLUSIONS: Our study found a statistically significant but not clinically significant improvement of LBP after surgical repair of prolapse.

Asynchronous telehealth visits for the treatment of overactive bladder.

OBJECTIVE: Overactive bladder affects 17% of women, and adherence to treatment is notoriously low. The objective of this pilot study is to investigate the efficacy and feasibility of the use of asynchronous telehealth visits for the treatment of women with overactive bladder. METHODS: This is a pilot study of women who participated in the asynchronous telehealth program with a new diagnosis of overactive bladder presenting to the Massachusetts General Hospital from January of 2020 to March of 2021. Pre-post differences in Urogenital Distress Inventory score-6, and Incontinence Severity Index Scores were compared with paired t tests as coprimary endpoints. To assess potential mechanisms of association between asynchronous visits and patient-reported outcomes, total fluid intake, caffeinated beverage consumption, urinary frequency, episodes of urinary leakage were also compared as secondary endpoints. RESULTS: A total of 23 women participated, with 50 e-visits completed. The first asynchronous visit was completed after a median of 42days (IQR 36, 51.5) from the initial visit. There was a decrease in the Urogenital Distress Inventory-6 score between the first asynchronous visit and the last (29 points, IQR 16, 37 vs 12 points, IQR 12, 25), respectively (P = 0.014). Similar findings were seen with the Incontinence Severity Index questionnaire, from three (IQR 2, 4) to three (IQR 1, 3) after the asynchronous visit (P = 0.002). CONCLUSION: We demonstrate the feasibility of asynchronous visits for the treatment of overactive bladder. Although our results suggest efficacy, given the prepost change in overactive bladder-related questionnaire scores following asynchronous visits, the comparative effectiveness of asynchronous visits versus regular care needs to be confirmed in a randomized trial.

Video Summary:http://links.lww.com/MENO/A917 .

Decision aids and shared decision making in urogynecology.

OBJECTIVES: To examine the efficacy and acceptability of decision aids (DAs) in counseling urogynecology patients with prolapse, stress urinary incontinence, or refractory overactive bladder. METHODS: This pilot study enrolled 33 patients into a control group that underwent usual care without a DA, followed by 33 patients into an intervention group where providers utilized a DA for counseling. Postvisit patient surveys assessed differences in treatment preference, knowledge, and in patient-physician collaboration using SURE, CollaboRATE, and Shared Decision Making (SDM) Process scales. Postvisit provider surveys assessed their perception of the usefulness and the difficulty of using a DA and visit length. Independent t tests were used for continuous variables (Knowledge and SDM Process scores) and Chi-Square for categorical variables (treatment preference, SURE, and CollaboRATE). RESULTS: The majority of eligible patients 66/71 (93%) completed the survey. The intervention group trended toward higher knowledge scores (72% vs 60%, P  = 0.06), clearer treatment preferences (85% vs 67%, P  = 0.08), higher rates of top SURE scale scores (91% vs 73%, P  = 0.11), and top CollaboRATE scores (75% vs 52%, P  = 0.07). SDM process scores were similar across groups (3.2 vs 3.2, P  = 0.96). Providers used the DA in 73% of intervention group visits and rated the visit length as "normal" in both groups (70% vs 76%, P  = 0.78). CONCLUSIONS: There were no statistically significant differences between the control group and the intervention group. The use of DAs was acceptable to providers and indicated a trend toward increased patient knowledge, treatment preference, and satisfaction. A larger study is warranted to examine the impact of DAs on decision making and patient experience.

Video Summary:http://links.lww.com/MENO/A856 .

Cohort study of impact on length of stay of individual enhanced recovery after surgery protocol components.

OBJECTIVE: The goal of this study was to explore which enhanced recovery after surgery (ERAS) bundle items were most associated with decreased length of stay after surgery, most likely associated with decreased length of stay after surgery. DESIGN: A cohort study. SETTING: Large tertiary academic medical centre. PARTICIPANTS: The study included 1318 women undergoing hysterectomy as part of our ERAS pathway between 1 February 2018 and 30 January 2020 and a matched historical cohort of all hysterectomies performed at our institution between 3 October 2016 and 30 January 2018 (n=1063). INTERVENTION: The addition of ERAS to perioperative care.This is a cohort study of all patients undergoing hysterectomy at an academic medical centre after ERAS implementation on 1 February 2018. Compliance and outcomes after ERAS roll out were monitored and managed by a centralised team. Descriptive statistics, multivariate regression, interrupted time series analysis were used as indicated. MAIN OUTCOME MEASURES: Impact of ERAS process measure adherence on length of stay. RESULTS: After initiation of ERAS pathway, 1318 women underwent hysterectomy. There were more open surgeries after ERAS implementation, but cohorts were otherwise balanced. The impact of process measure adherence on length of stay varied based on surgical approach (minimally invasive vs open). For open surgery, compliance with intraoperative antiemetics (-30%, 95% CI -18% to 40%) and decreased postoperative fluid administration (-12%, 95% CI -1% to 21%) were significantly associated with reduced length of stay. For minimally invasive surgery, ambulation within 8 hours of surgery was associated with reduced length of stay (-53%, 95% CI -55% to 52%). CONCLUSIONS: While adherence to overall ERAS protocols decreases length of stay, the specific components of the bundle most significantly impacting this outcome remain elusive. Our data identify early ambulation, use of antiemetics and decreasing postoperative fluid administration to be associated with decreased length of stay.

Pelvic floor laxity: A not so rare but unrecognized form of daytime urinary incontinence in peripubertal and adolescent girls.

INTRODUCTION: Stress urinary incontinence (SUI) is common among older multiparous females but rarely reported in active, young girls. OBJECTIVES: Our hypothesis is: physically active adolescent females develop pelvic floor laxity demonstrable on upright VCUG. Our objectives are to (1) increase awareness of SUI in young females, (2) test our hypothesis with an upright VCUG, and (3) report effectiveness of step-wise management. STUDY DESIGN: A retrospective review was performed of nulliparous girls with only SUI seen from 2000 to 2015, who were evaluated with upright voiding cystourethrography (VCUG) (bladder descent defined as ≥2 cm drop of bladder neck below pubic ramus at capacity). Data collection included level of physical activity, physical examination, BMI and Z-scores, urodynamics, management, and treatment response. Standard urotherapy (SUT) (timed voiding, proper diet, adequate fluids, bowel management) and biofeedback therapy (BFT) was initiated. Fisher exact test was used to calculate 'p' values. RESULTS: Thirty-three females (median age 15.1 years, range 5.5-20.3) were identified who underwent an upright VCUG; 20 had bladder neck descent (Fig.). Of these 20, 15 (75%) were involved in strenuous activity, whereas only three of 13 (23%) without descent engaged in intense athletics. No differences were noted in median BMI and Z-score with strenuous activity (21.1 (15.2-26.7) and 0.31 (-0.9-1.94)), respectively, versus patients without (21.3 (15.8-33.5) and 0.62 (-0.0-2.38)). Average follow-up for all was 16.6 months (range 0.4-102.2). Of 20 demonstrating bladder neck descent, three did not complete therapy and were lost to follow-up. Only six of these 17 became dry. Of the remaining 11, eight underwent surgery: Burch colposuspension (5), fascial sling (2), Coaptite to the bladder neck (1), and an artificial urinary sphincter (1). This latter girl had a failed Burch colposuspension 1 year previously. All surgical patients are dry. Of 13 without bladder descent on VCUG, five did not complete therapy and were lost to follow-up. The remaining eight were managed non-surgically; seven were fully dry at last follow-up. Overall, 13 of 25 (52%) achieved dryness. SUT and BFT were more effective in those without, than in those with bladder descent (87.5% vs. 35.3%, p = 0.0302, Fisher exact test). DISCUSSION AND CONCLUSIONS: Physically active, nulligravid girls with SUI can be efficaciously diagnosed on upright VCUG. They should be considered for non-surgical therapy but will likely require bladder neck elevating surgery. Non-surgical therapy works for those with minimal bladder descent on cystography.

Hormone Modulation of Toll-Like Receptor 5 in Cultured Human Bladder Epithelial Cells.

AIM: The effect of hormone levels on the stimulation of Toll-like receptor 5 (TLR5) in the bladder is unknown. We aimed to study the effect of estradiol and progesterone on TLR5 expression and function in human bladder epithelial cells. METHODS: After growing to near confluence, T24 human urinary bladder (HUB) cells were incubated in hormone-free (HF) media for 72 hours. Human urinary bladder cells were then incubated in (1) HF media, (2) estradiol media, (3) progesterone media, or (4) media containing estradiol and progesterone at physiologic concentrations. Following flagellin exposure, cells and media were collected. Toll-like receptor 5 expression and stimulated cytokine release were analyzed using enzyme-linked immunosorbent assays. Results were normalized with cellular protein assays. A TLR5 antagonist was used to confirm that stimulation from flagellin was mediated by TLR5 signaling. RESULTS: Cultured HUB cells express TLR5 protein. Estradiol and progesterone environments suppress TLR5 expression compared to HF environment. The function of TLR5 was measured by interleukin 6 (IL-6) and monocyte chemoattractant protein 1 production after flagellin exposure. Interleukin 6 production was 75% higher in the estradiol than progesterone environment. The progesterone environment produced IL-6 levels twice that observed in HF and combined estrogen-progesterone environments. Interestingly, higher TLR5 expression was associated with lower IL-6 production. CONCLUSION: Our study demonstrated that TLR5 expression and functional activity as measured by IL-6 are modulated by hormones. The increase in TLR5-associated IL-6 may play a role in increasing the rate of symptomatic urinary tract infection. Likewise, low TLR5 functional activity may dampen the response of the innate immune system, thereby lessening the likelihood of a symptomatic bladder infection.

In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort.

BACKGROUND: The indications for operation in patients with obstructed defecation syndrome (ODS) with rectocele are not well defined. METHODS: A total of 90 female patients with ODS and rectocele were prospectively evaluated and treated with fiber supplements and biofeedback training. Univariate and multivariate regression was used to determine factors predictive of failing medical management. RESULTS: Obstructive symptoms were the most prevalent presenting complaint (82.2%). Ultimately, 71.1% of patients responded to medical management and biofeedback. Multivariate regression analysis suggested that the presence of internal intussusception was associated with a lower chance of undergoing surgery to address ODS symptoms [odds ratio 0.18; P = .05], whereas inability to expel balloon, contrast retention on defecography, and splinting were not (P ≥ .15). CONCLUSION: Rectoceles with concomitant intussusception in patients with ODS appear to portend a favorable response to biofeedback and medical management. We argue that all patients considered for surgery for rectoceles because of ODS should first undergo appropriate bowel retraining.

Minimally invasive apical sacropexy: a retrospective review of laparoscopic and robotic operating room experiences.

OBJECTIVES: Minimally invasive apical sacropexies (MI-APSC) can be performed using robotics or laparoscopy. We hypothesized that operative characteristics of MI-APSC, laparoscopic (LSC) and robotic (RSC), were similar. The objective of our study was to compare operative characteristics, objective prolapse outcomes, and robotic learning curve. METHODS: Ninety-two women planning MI-APSC for treatment of apical pelvic organ prolapse from 2006 to 2010 were included in the study. The primary outcome was operative time. The secondary outcomes included estimated blood loss, rate of conversion, intraoperative complications, hospital stay, and objective prolapse outcome. We also analyzed the robotic learning curve. Statistical analysis included independent samples t test, Wilcoxon rank sum test, χ, and multiple logistic regressions; significance was set at P < 0.05. Learning curve was graphed with moving average and analyzed with moving block technique. RESULTS: Forty-eight RSCs and 43 LSCs were analyzed. Mean operative times were LSC, 238 ± 59 minutes; and RSC, 242 ± 54 minutes. Robotic MI-APSC setup was longer (P = 0.02). Complications, conversions, estimated blood loss and hospital stay were low and similar between groups. Patients' characteristics were similar. Concomitant procedures produced longer operative times. CONCLUSIONS: Operating room experiences with laparoscopic- and robotic-assisted approaches to MI-APSC were similar, but setup time is longer for the robotic-assisted approach. The robotic learning curve is short for surgeons who have experience with LSC.

Development of de novo urge incontinence in women post sling: the role of preoperative urodynamics in assessing the risk.

AIMS: The study was undertaken to investigate if there are specific identifiable risk factors on the preoperative history or urodynamics testing associated with an increased risk for the development of symptoms of de novo urge urinary incontinence after a minimally invasive sling procedure. METHODS: Two hundred eighty-one women who had undergone minimally invasive sling surgery for stress urinary incontinence between January 2000 and December 2003 were identified. The records of 92 patients were included in this review. RESULTS: Twenty-five patients (27%) reported urge urinary incontinence on postoperative questioning. Clinical and urodynamic parameters were correlated with the development of de novo urge urinary incontinence. Preoperative history parameters were not predictive of the increased risk of de novo urge urinary incontinence, with the exception of increased preoperative daytime frequency (OR 3.3 (1.2, 9.1)). Of 16 women whose detrusor pressure during the filling phase of cystometry exceeded 15 cm H(2)O, de novo urge urinary incontinence developed in 9 (56%) vs. 16 (21%) of 76 women, whose detrusor pressure was < or = 15 cm H(2)O (OR 4.6 (1.4, 15.0)). CONCLUSIONS: Directed patient history is only minimally helpful in the identification of women at increased risk for the development of de novo urge urinary incontinence, with the exception of the complaint of increased daytime frequency. Women with elevated detrusor pressure during the filling phase of cystometry were more likely to develop urge urinary incontinence postoperatively. Therefore, we suggest that preoperative urodynamic evaluation, and specifically detrusor pressure > 15 cm H(2)O may help identify patients at increased risk of developing de novo urge urinary incontinence following the minimally invasive sling procedure.