It Takes a Village: The First 100 Patients Seen in a Multidisciplinary Pelvic Floor Clinic.

OBJECTIVE: This study aimed to assess the characteristics of patients assessed and treated at a multidisciplinary pelvic floor program that includes representatives from multiple specialties. Our goal is to describe the process from triaging patients to the actual collaborative delivery of care. This study examines the factors contributing to the success of our multidisciplinary clinic as evidenced by its ongoing viability. METHODS: This is a descriptive study retrospectively analyzing a prospectively maintained database that included the first 100 patients seen in the Program for Abdominal and Pelvic Health clinic between December 2017 and October 2018. We examined patient demographics, their concerns, and care plan including diagnostic tests, findings, treatments, referrals, and return visits. RESULTS: The clinic met twice monthly, and the first 100 patients were seen over the course of 10 months. The most common primary symptoms were pelvic pain (45), constipation (30), bladder incontinence (27), bowel incontinence (23), high tone pelvic floor dysfunction (23), and abdominal pain (23); most patients had more than one presenting symptom (76). The most common specialties seen at the first visit to the clinic included gastroenterology (56%), followed by physical medicine and rehabilitation (45%), physical therapy (31%), female pelvic medicine and reconstructive surgery (25%), behavioral health (19%), urology (18%), and colorectal surgery (13%). Eleven patients were entirely new to our hospital system. Most patients had diagnostic tests ordered and performed. CONCLUSIONS: A multidisciplinary clinic for abdominal and pelvic health proves a sustainable model for comprehensive treatment for patients with pelvic floor dysfunction, including difficulties with defecation, urination, sexual dysfunction, and pain.

Consideration of pelvic floor myofascial release for overactive bladder.

INTRODUCTION: Physical therapy has been shown to be effective for women with overactive bladder (OAB). We report on our experience with pelvic floor physical therapy (PFPT) with or without myofascial release as treatment for women with symptoms of urinary urgency or urge incontinence. METHODS: We performed a retrospective chart review, of patients who presented to our tertiary care Urogynecology practice. These women were evaluated and treated between August 2016 and December 2016. We abstracted for symptoms as per history of present illness and the pelvic floor muscle examination. PFPT progress notes were reviewed to determine whether patients received myofascial release techniques, or if therapy was limited to behavioral interventions and urge suppression techniques. We recorded the number of PFPT sessions attended, and whether the patient reported improvement. RESULTS: 77 patients with symptoms of OAB met inclusion criteria and initiated PFPT. Myofascial tenderness of the pelvic floor muscles was found in 56.5% of patients. PFPT was limited to behavioral and urge suppression in 18 patients, while 59 patients received myofascial release techniques. Improvement was reported by 71.4% (n = 55/77) of patients. Improvement increased with number of sessions attended: 1-2: 6% (1/17), 3-5: 94% (16/17), 6-8: 91% (29/32), and >8: 80% (9/11) improved, respectively (p < 0.001). Among patients who had myofascial release, 84.7% reported improvement when compared to only 27.8% of patients without myofascial release. CONCLUSIONS: The data support the inclusion of myofascial release during pelvic floor physical therapy for overactive bladder. At least three sessions of PFPT are necessary for patient reported improvement.

Screening for Microscopic Hematuria in a Urogynecologic Population.

OBJECTIVES: The objectives of this were to determine the correlation of greater than or equal to 3 red blood cells per high-power field (RBCs/HPF) with a positive urine dipstick for blood and to identify clinically relevant factors than can influence this relationship. METHODS: The charts of women with positive blood urine dipsticks were reviewed from August 2012 to August 2013. The cohort of women was divided into 2 groups; those with urine with greater than or equal to 3 RBCs/HPF on microscopy and those without. Relevant clinical and demographic variables were extracted from the electronic medical record. Data analysis was conducted using SAS version 9.4 (SAS Institute, Cary, NC). RESULTS: Most of the 203 patients eligible for analysis were Caucasian, and the total cohort had a mean age of approximately 62.8 years. Microscopy confirmed greater than or equal to 3 RBCs/HPF in 25.6% of the urine samples. A dipstick finding of moderate or large blood was significantly more likely to have greater than or equal to 3 RBCs/HPF on univariate and multivariable analyses (P < 0.001). Factors significantly associated with greater than or equal to 3 RBCs/HPF were increasing age, recurrent urinary tract infections, and urinary specific gravity of greater than 1.010. CONCLUSIONS: Lower urinary specific gravities appear to be associated with underestimating microhematuria, likely owing to the underrepresentation of the true number of red blood cells. Urine dipstick indicators of moderate or large blood increase the likelihood the microscopy samples demonstrated greater than or equal to 3 RBCs/HPF. These findings suggest that clarification of microhematuria detection and evaluation guidelines should be considered, given both important clinical and economic consequences.

Pelvic floor myofascial pain in patients with symptoms of urinary tract infection.

OBJECTIVE: To correlate lower urinary tract symptoms typically associated with a urinary tract infection (UTI) with physical examination findings of pelvic floor myofascial pain (PFMP). METHODS: This retrospective review included all new patients presenting to a urogynecology clinic between August 2 and December 19, 2016. Patients completed validated questionnaires, had a catheterized urine specimen, and underwent pelvic examination. Associations between demographics, symptoms, urine culture, and PFMP were analyzed. RESULTS: We included 250 patients with urinary frequency (n=160, 64.0%), urgency (n=155, 62.0%), urgency incontinence (n=140, 56.0%), pelvic pain (n=43, 17.2%), and dysuria (n=25, 10.0%). PFMP was detected in 125 (50.0%) patients and culture-proven UTI in 15 (6.0%) patients. Demographics associated with PFMP were lower prolapse stage (P<0.001), age younger than 50 years (P<0.001), lower parity (P=0.028), and non-white ethnicity (P=0.003). Symptoms associated with PFMP were dysuria (adjusted odds ratio 4.13, 95% confidence interval 1.08-15.78), urgency/frequency (2.72, 1.47-5.04), and patient-reported pelvic pain (2.57, 1.08-6.12). These symptoms were independent predictors in multivariable logistic regression analysis. CONCLUSIONS: Most patients had symptoms associated with UTI; however, culture-confirmed diagnosis was infrequent and PFMT was diagnosed in half of participants. Clinicians treating women with these symptoms are advised to examine the pelvic floor muscles.

IL22 regulates human urothelial cell sensory and innate functions through modulation of the acetylcholine response, immunoregulatory cytokines and antimicrobial peptides: assessment of an in vitro model.

Human urinary disorders are generally studied in rodent models due to limitations of functional in vitro culture models of primary human urothelial cells (HUCs). Current HUC culture models are often derived from immortalized cancer cell lines, which likely have functional characteristics differ from healthy human urothelium. Here, we described a simple explant culture technique to generate HUCs and assessed their in vitro functions. Using transmission electron microscopy, we assessed morphology and heterogeneity of the generated HUCs and characterized their intercellular membrane structural proteins relative to ex vivo urothelium tissue. We demonstrated that our cultured HUCs are free of fibroblasts. They are also heterogeneous, containing cells characteristic of both immature basal cells and mature superficial urothelial cells. The cultured HUCs expressed muscarinic receptors (MR1 and MR2), carnitine acetyltransferase (CarAT), immunoregulatory cytokines IL7, IL15, and IL23, as well as the chemokine CCL20. HUCs also expressed epithelial cell-specific molecules essential for forming intercellular structures that maintain the functional capacity to form the physiological barrier of the human bladder urothelium. A subset of HUCs, identified by the high expression of CD44, expressed the Toll-like receptor 4 (TLR4) along with its co-receptor CD14. We demonstrated that HUCs express, at the mRNA level, both forms of the IL22 receptor, the membrane-associated (IL22RA1) and the secreted soluble (IL22RA2) forms; in turn, IL22 inhibited expression of MR1 and induced expression of CarAT and two antimicrobial peptides (S100A9 and lipocalin-2). While the cellular sources of IL22 have yet to be identified, the HUC cytokine and chemokine profiles support the concept that IL22-producing cells are present in the human bladder mucosa tissue and that IL22 plays a regulatory role in HUC functions. Thus, the described explant technique is clearly capable of generating functional HUCs suitable for the study of human urinary tract disorders, including interactions between urothelium and IL22-producing cells.

Vaginal cancer in a patient with complicated prolapse history: a case report.

BACKGROUND: In the setting of multiple pelvic floor procedures, vaginal abnormalities are not unusual. CASE: We present the case of a 59-year-old woman with voiding dysfunction and inability to have intercourse after multiple pelvic floor procedures who presented with a vaginal mass on bimanual examination, thought to be related to prior procedures with permanent sutures. Imaging was obtained, and the lesions were thought to be suture granuloma. She was taken to the operating room for relaxing incision of her posterior repair and excision of suture granuloma. She was found to have squamous cell carcinoma of the vagina. CONCLUSIONS: In the differential of any vaginal abnormality, although rare, vaginal cancer should be included in the differential diagnosis.

Snoring during pregnancy and delivery outcomes: a cohort study.

STUDY OBJECTIVE: This cohort study examined the impact of maternal snoring on key delivery outcomes such as mode of delivery, infant birth centile, and small-for-gestational age. DESIGN: Cohort study. SETTING: A large tertiary medical center. PATIENTS OR PARTICIPANTS: Pregnant women in their third trimester were recruited between March 2007 and December 2010. MEASUREMENTS AND RESULTS: Women were screened for habitual snoring, as a known marker for sleep disordered breathing. Outcome data were obtained from medical records following delivery and birth centiles were calculated. Of 1,673 women, a total of 35% reported habitual snoring (26% with pregnancy-onset snoring and 9% with chronic snoring). After adjusting for confounders, chronic snoring was associated with small-forgestational age (OR 1.65, 95%CI 1.02-2.66, P = 0.041) and elective cesarean delivery (OR 2.25, 95%CI 1.22-4.18, P = 0.008). Pregnancy-onset snoring was associated with emergency cesarean delivery (OR 1.68, 95%CI 1.22-2.30, P = 0.001). CONCLUSION: Maternal snoring during pregnancy is a risk factor for adverse delivery outcomes including cesarean delivery and small-for-gestational age. Screening pregnant women for symptoms of SDB may provide an early opportunity to identify women at risk of poor delivery outcomes. CLINICAL TRIALS REGISTRATION: IDENTIFIER: NCT01030003.

Skill acquisition, credentialing, and maintenance of skills in surgical treatment of pelvic organ prolapse and urinary incontinence.

Female pelvic medicine and reconstructive surgery, or urogynecology, has undergone a unique evolution with recent recognition as a subspecialty of Obstetrics and Gynecology and Urology. It has never suffered from a shortage of innovation nor of innovators, and thus new treatments and therapeutic options are regularly being introduced. Who is best to perform or prescribe new, therapeutic options and their implementation in a responsible manner is controversial. In this chapter, we will review skill acquisition, credentialing, and the maintenance of skills in surgical treatment of pelvic organ prolapse and urinary incontinence.

Vulvar ulcer causing osteomyelitis of the pubic bone.

BACKGROUND: Osteomyelitis of the pubic bone is a rare entity. Risk factors for infection of the symphysis pubis and osteomyelitis of the pubic bone include direct trauma, previous urogynecologic procedures, extreme physical exercise, and immunocompromised state. The treatment modalities range from conservative antibiotic treatment to extensive surgery. CASE: A 49-year-old woman with multiple sclerosis and borderline diabetes mellitus presented with bloody vulvovaginal discharge. The source was found out to be an ulcer located above the urethra with exposure of the underlying symphysis pubis. Intraoperative debridement of the ulcer followed by bone biopsies demonstrated osteomyelitis of the pubic bone. Prolonged intravenous antibiotics and 4 operative debridements were needed before the osteomyelitis was adequately addressed and the defect could be closed with a bulbocavernosus flap. CONCLUSIONS: This is the first report of a severe case of osteomyelitis of the pubic bone arising from a vulvar ulcer.

Pregnancy-onset habitual snoring, gestational hypertension, and preeclampsia: prospective cohort study.

OBJECTIVE: This study aimed to prospectively examine the impact of chronic vs pregnancy-onset habitual snoring on gestational hypertension, preeclampsia, and gestational diabetes. STUDY DESIGN: Third-trimester pregnant women were recruited from a large, tertiary medical center from March 2007 through December 2010 and screened for the presence and duration of habitual snoring, as a known marker for sleep-disordered breathing. Clinical diagnoses of gestational hypertension, preeclampsia, and gestational diabetes were obtained. RESULTS: Of 1719 pregnant women, 34% reported snoring, with 25% reporting pregnancy-onset snoring. After adjusting for confounders, pregnancy-onset, but not chronic, snoring was independently associated with gestational hypertension (odds ratio, 2.36; 95% confidence interval, 1.48-3.77; P < .001) and preeclampsia (odds ratio, 1.59; 95% confidence interval, 1.06-2.37; P = .024) but not gestational diabetes. CONCLUSION: New-onset snoring during pregnancy is a strong risk factor for gestational hypertension and preeclampsia. In view of the significant morbidity and health care costs associated with hypertensive diseases of pregnancy, simple screening of pregnant women may have clinical utility.

Urethral closure pressures among primiparous women with and without levator ani muscle defects.

INTRODUCTION AND HYPOTHESIS: Vaginal birth is an established risk factor for levator ani (LA) defects and incontinence. We hypothesized an association between urethral pressure profiles and LA defects. METHODS: One hundred sixty primiparous women, 9-12 months postpartum, were assessed with MRI for LA defects, urodynamic testing, and instrumented speculum for vaginal closure force. Urodynamic testing included resting maximal urethral closure pressure (MUCP) and urethral closure pressure with a pelvic floor contraction or Kegel (KUCP). We examined the relationships between MUCP, KUCP, LA defect status, and vaginal closure force. RESULTS: There was no significant association between MUCP or KUCP in women with and without LA defects (p = 0.94, p = 0.95). Additionally, there was no correlation between MUCP and vaginal closure force (r = 0.06, p = 0.41), and a weak correlation between KUCP and vaginal closure force (r = 0.20, p = 0.01). CONCLUSIONS: In this population, urethral pressure profiles are unrelated to LA defect status after vaginal birth, indicating that the mechanism responsible for LA damage spares the urethra.

Levator defects affect perineal position independently of prolapse status.

OBJECTIVE: The purpose of this study was to determine the effect of levator defects on perineal position and movement irrespective of prolapse status. STUDY DESIGN: Forty women from an ongoing study were divided into 2 groups of 20 women with and without severe levator defects. Prolapse status was matched between groups, with 50% of the women having stage III or greater anterior wall prolapse. Perineal structure locations were measured against standard axes on magnetic resonance scans at rest, maximum contraction (Kegel), and maximum Valsalva maneuver. Differences in location were calculated and compared. RESULTS: In women with levator defects, independently of prolapse status: (1) At rest, the perineal body was 1.3 cm, and the anal sphincter was 1.0 cm more caudal (P ≤ .01); at maximum contraction, the perineal body and the anal sphincter were both 1.2 cm more caudal (P ≤ .01); with maximum Valsalva maneuver, the perineal body was 1.3 cm more caudal, and the anal sphincter was 1.2 cm more caudal (P ≤ .01). (2) At rest, the levator hiatus was 0.8 cm larger, and the urogenital hiatus was 1.0 cm larger (P ≤ .01). (3) At rest, the bladder was 0.07 cm more posterior (P ≤ .02); with maximum contraction, it was 1.9 cm lower (P ≤ .02). (4) With maximum Valsalva maneuver, the bladder was 1.5 cm lower and displaced further caudally (P ≤ .03). CONCLUSION: When we controlled for prolapse, the women with levator defects had a more caudal location of their perineal structures and larger hiatuses at rest, maximum contraction, and maximum Valsalva maneuver.

Anterior vaginal wall prolapse: assessment and treatment.

Assessment and management of anterior vaginal wall defects presents a unique surgical challenge. It is often the most common site of initial prolapse in women and the most common site of recurrence. This chapter discusses the anatomy, evaluation, and surgical approach to the treatment of anterior vaginal wall defects. We also review outcomes of various surgical approaches and discuss why the anterior vaginal wall presents such a challenge.

Management of vulvovaginal strictures/shortened vagina.

Vaginal strictures are generally difficult to manage and tend to reccur despite appropriate initial therapy. Vaginal dilation with or without surgery is the main stay of treatment. Causes, diagnosis and management of the vulvovaginal strictures are presented.