Pelvic floor disorder assessment of knowledge and symptoms: an educational intervention for Spanish-speaking women (PAKS study).

INTRODUCTION AND HYPOTHESIS: Educational interventions have been effective in improving postpartum knowledge, performance of pelvic floor exercises, and bowel-specific quality-of-life. Our primary objective was to determine if a video-based educational intervention on pelvic floor disorders (PFDs) would increase Spanish-speaking women's knowledge of PFDs, and secondarily to assess if it would decrease pelvic floor symptoms. We hypothesized that Spanish-speaking women would improve their pelvic floor knowledge and symptoms post-intervention. METHODS: Inclusion criteria included women age 18 years and older and self-reported as a predominantly Spanish-speaker or equally bilingual English- and Spanish-speaker. Changes in knowledge were assessed with the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). Changes in symptoms were assessed with the Pelvic Floor Distress Inventory-20 (PFDI-20). Linear regression assessed for independent effects. RESULTS: One hundred and fourteen women were enrolled and 112 completed the pre- and post-intervention PIKQ. Mean (standard deviation [SD]) age was 50 (14) years. Immediate post-intervention scores showed significant improvement in knowledge. Total PIKQ score improved by 5.1 (4.7) points (p < 0.001). POP subscore improved by 2.7 (2.7) points (p<0.001) and UI subscore improved by 2.3 (2.5) points (p < 0.001). Improvement in knowledge continued after four weeks (p < 0.001). PFDI-20 prolapse (p=0.02), colorectal-anal (p < 0.001) and urinary (p = 0.01) scores significantly improved only for the most symptomatic women at baseline. Using linear regression, total PIKQ (p = 0.03) and total PFDI-20 scores (p = 0.04) were associated with predominantly Spanish-speakers versus fully bilingual. CONCLUSION: Findings support the efficacy of a video-based educational intervention to improve knowledge of PFDs in Spanish-speaking women. The most symptomatic women benefitted from this intervention.

The impact of anxiety on postoperative pain following pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Despite the prevalence of anxiety, its impact on postoperative pain remains poorly characterized. The present study was aimed at assessing the impact of preoperative anxiety on postoperative pain in patients undergoing pelvic reconstructive surgery. We hypothesized that greater anxiety would be associated with increased postoperative pain for patients undergoing pelvic reconstructive surgery. METHODS: This was a prospective multi-center observational study in Baltimore between September 2018 and June 2019. The Beck Anxiety Inventory was used to assess preoperative anxiety and the validated Surgical Pain Scale instrument was used to assess pain in the postoperative period. The association between anxiety and postoperative pain was analyzed using multivariate logistic regression, adjusting for relevant confounders. RESULTS: A total of 149 patients undergoing pelvic reconstructive surgery completed preoperative surveys. The median age of the study population was 59. The prevalence of preoperative anxiety (anxiety score > 9) in our study population was 26.8% (95% CI 19.7-34.0%). Women with preoperative anxiety reported higher postoperative pain on days 1-2 (relative odds 1.05, 95% confidence interval 1.01-1.10) and day 14 (relative odds 1.53, 95% confidence interval 1.00-2.34). CONCLUSIONS: A large fraction of women undergoing pelvic reconstructive surgery have moderate to severe preoperative anxiety. Women with preoperative anxiety appear to have greater odds of increased postoperative pain. Understanding this association may help surgeons with preoperative counseling and expectations regarding postoperative pain.

Obstructed defecation syndrome in the first week after pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Research shows that patients are concerned about postoperative bowel function after pelvic reconstructive surgery. The objectives of this study were to estimate the proportion of patients with obstructed defecation syndrome (ODS), a subtype of constipation, in the week after surgery, to identify associated patient-level and perioperative characteristics and the associated bother. METHODS: Women completed a preoperative and postoperative ODS questionnaire and postoperative bowel diary. Characteristics of women with and without postoperative ODS were compared. Chi-squared or Fisher's exact tests compared categorical variables. Student's t test or Wilcoxon rank-sum tests compared continuous variables. Multivariate logistic regression was assessed for independent effects. Wilcoxon rank-sum tests compared the groups with regard to bother. Spearman correlation coefficients described the relationship among bother, postoperative ODS score, and bowel diary variables. RESULTS: Of the 186 participants enrolled, 165 completed the postoperative ODS questionnaire. Of these, 39 women (23.6%, 95% CI 17.2-30.1) had postoperative ODS. Postoperative ODS was significantly associated with preoperative ODS (p < 0.001), posterior colporrhaphy (p = 0.03), surgery type (p = 0.01), and longer duration of surgery (p = 0.03). Using multivariate logistic regression controlling for age, only preoperative ODS was significantly associated with postoperative ODS (OR 2.68, 95% CI 1.73-4.17). Women with postoperative ODS reported more bother with their defecatory symptoms (p < 0.001). The degree of bother was significantly associated with postoperative ODS score (p < 0.001). CONCLUSION: Using a validated disease-specific questionnaire to identify ODS, this complication was identified in 23.6% of patients in the week after pelvic reconstructive surgery. Preoperative ODS was a significant and important risk factor for this complication.

Surgical Repair of the Genital Hiatus: A Narrative Review.

INTRODUCTION AND HYPOTHESIS: An enlarged genital hiatus (GH) is associated with the development of prolapse and may be associated with prolapse recurrence following surgery; however, there is insufficient evidence to support surgical reduction of the GH as prophylaxis against future prolapse. The objective of this review is (1) to review the association between GH size and pelvic organ prolapse and (2) to discuss the existing literature on surgical procedures that narrow the GH. METHODS: A literature search was performed in the PubMed search engine, using the keyword "genital hiatus." Articles were included if they addressed any of the following topics: (1) normative GH values; (2) associations between the GH and prolapse development or recurrence; (3) surgical alteration of the GH; (4) indications, risks or benefits of surgical alteration of the GH. RESULTS: An enlarging GH has been observed prior to the development of prolapse. Multiple studies show that an enlarged pre- and/or postoperative GH is associated with an increased risk of recurrent prolapse following prolapse repair surgery. There are limited data on the specific risks of GH alteration related to bowel and sexual function. CONCLUSIONS: GH size and prolapse appear to be strongly associated. Because GH size appears to be a risk factor for pelvic organ prolapse, the GH size should be carefully considered at the time of surgery. Surgeons should discuss with their patients the risks and potential benefits of additional procedures designed to reduce GH size.

The role of the genital hiatus and prolapse symptom bother.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) severity is poorly correlated with prolapse symptoms. The objective of this study was to investigate the association between genital hiatus (GH) size and presence and severity of bulge symptoms. METHODS: This analysis utilized data from a longitudinal study of parous women. Women underwent annual assessment of POP, GH size, and bulge symptoms. "Bother" was scored by participants reporting bulge symptoms. Three analyses evaluated the association between GH size and bulge symptoms, each using linear mixed models. First, we compared case visits (bulge symptoms reported) to control visits (bulge symptoms never reported), matching for stage. Second, among women who reported bulge sensation at least once during the study, we compared GH size at visits with and without bulge symptoms. Third, among women who reported bulge sensation, we investigated whether GH size was associated with "bother" score, controlling for stage. RESULTS: Of 1528 women (7440 visits), 148 women (803 visits) reported bulge symptoms at ≥ 1 visit and 1380 women never reported bulge symptoms (6637 visits). Comparing 315 case visits (bulge symptoms reported) to 1260 control visits (bulge symptoms never reported), GH size was significantly greater among case visits (3.05 cm versus 2.85 cm, p ≤ 0.0001). In the case-crossover analysis, GH size was similar for visits with and without bulge symptoms (p = 0.63). When evaluating GH size and degree of bulge symptom bother, bother severity was significantly associated with GH size (p = 0.003). CONCLUSIONS: Independent of stage, GH size was significantly associated with prolapse bulge symptoms and bother severity.

Prevalence of stress urinary incontinence and intrinsic sphincter deficiency in patients with stage IV pelvic organ prolapse.

AIM: To determine the prevalence of stress urinary incontinence (SUI) and intrinsic sphincter deficiency (ISD) in women with stage IV pelvic organ prolapse. METHODS: Retrospective analysis of women with stage IV prolapse who underwent multichannel urodynamic testing. Abdominal leak point pressures (ALPP) and maximum urethral closure pressures (MUCP) were recorded. ISD was defined as ALPP ≤60 cm of water and/or MUCP ≤20 cm of water. Percentages were used to present the proportion of subjects diagnosed with SUI and ISD. RESULTS: A total of 145 patients met inclusion criteria. Mean age was 69 years; most patients were Caucasian (56%). Eighty-two (56%) patients were found to have SUI on urodynamic testing. Thirty-six (44%) of these were asymptomatic and identified as having occult SUI. Sixteen (19.5%) patients were diagnosed with ISD using ALPP and/or MUCP. Six (37%) of the ISD patients had at least one MUCP value ≤20 cm of water and 12 (75%) had observed leakage with at least one ALPP value ≤60 cm of water. The number of patients with leakage at ALPP ≤60 cm of water increased with increasing bladder volumes. Five ISD patients (31%) had ALPP ≤60 cm of water at 200 mL, six (37.5%) had ALPP ≤60 cm of water at 300 mL and seven (43.8%) had ALPP ≤60 cm of water at 400 mL. CONCLUSION: Greater than 50% of patients with stage IV pelvic organ prolapse had SUI on urodynamic testing, and 20% were found to have ISD. Of the patients diagnosed with SUI, 40% were asymptomatic. These findings may assist in counseling and preoperative planning for women with stage IV prolapse.

Creation and Implementation of Virtual Urogynecology Patient Cases for Medical Student Education.

Introduction: Urogynecologic disorders are highly prevalent, and many physicians across various specialties will encounter and care for patients with pelvic floor disorders. Yet most medical students have had limited to no experience in diagnosing and managing pelvic floor disorders, resulting in a gap in clinical education. Methods: Three virtual and interactive urogynecologic patient cases were developed on an e-learning platform with an overall goal of increasing clinical exposure to various pelvic floor disorders. The cases were integrated into the medical student obstetrics and gynecology clerkship during the 2020-2021 academic year (n = 40). Participants provided feedback regarding usability, acceptability, and educational value of the cases. Results: Twenty-one students (52%) completed the survey. Ninety percent (n = 19) agreed or strongly agreed that they were satisfied with the cases, and 71% (n = 15) agreed or strongly agreed that they would recommend the virtual patient cases to other students. All students (n = 21) felt that the format was easy to use and reported that the cases were appropriate for their level of learning. Most students felt that the cases increased or significantly increased their confidence regarding nonsurgical and surgical management options for pelvic floor disorders. Discussion: Our findings suggest that these interactive virtual patient cases are an acceptable, valuable, and effective tool for learners. Utilizing the cases can help mitigate existing disparities in exposure to pelvic floor disorders both highlighted by and preceding the COVID-19 pandemic.

Validation of a Spanish Version of the Prolapse and Incontinence Knowledge Questionnaire.

OBJECTIVE: The objective of this study was to validate a Spanish version of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). METHODS: Validation and reliability testing of the Spanish version of the PIKQ was conducted in 2 phases. In the first phase, a translation-back-translation method by 6 bilingual researchers was utilized to generate a final Spanish translation. In the second phase, bilingual women were randomized to complete the Spanish or English version first, followed by the alternate language. Agreement between individual items from English and Spanish versions was assessed by percent agreement and κ statistics. Intraclass correlation coefficients compared overall PIKQ scores and pelvic organ prolapse (POP) and urinary incontinence (UI) subscores. To establish test-retest reliability, we calculated Pearson correlation coefficients. In order to have a precision of 10% for 90% agreement, so that the lower 95% confidence interval would not be less than 80% agreement, 50 bilingual participants were required. RESULTS: Fifty-seven bilingual women were randomized and completed both versions of the PIKQ. Individual items showed 74%-97% agreement, good to excellent agreement (κ = 0.6-0.89) for 9 items and moderate agreement (κ = 0.4-0.59) for 14 items between English and Spanish PIKQ versions. Intraclass correlation coefficients of the overall score and POP and UI subscores showed excellent agreement (intraclass correlation coefficient = 0.81-0.91). Pearson correlation coefficients between initial and repeat Spanish scores were high: overall (r = 0.87) and for POP (r = 0.81) and UI subscores (r = 0.77). CONCLUSIONS: A valid and reliable Spanish version of the PIKQ has been developed to assess patient knowledge about UI and POP.

Common Urinary and Bowel Disorders in the Geriatric Population.

The prevalence of urinary incontinence and other lower urinary tract symptoms increases with older age. These symptoms are more noticeable in men after the seventh decade of life and in women after menopause. Constipation and fecal incontinence are major causes of symptoms in elderly patients and can significantly impair quality of life. This article summarizes the current literature regarding the occurrence and implications of lower urinary tract and bowel symptoms in the geriatric population.