Primary care providers practice patterns regarding female pelvic floor disorders.

INTRODUCTION: Pelvic floor disorders (PFDs) pose substantial physical and psychological burdens for a growing number of women. Given the ubiquity of these conditions and known patient reluctance to seek care, primary care providers (PCPs) have a unique opportunity to increase treatment and provide appropriate referrals for these patients. METHODS: An online survey was administered to PCPs to assess provider practices, knowledge, comfort managing and ease of referral for PFDs. Logistic regression was used to assess the association between demographic/practice characteristics of PCPs and two primary outcomes of interest: discomfort with management and difficulty with referral of PFDs. RESULTS: Of the 153 respondents to the survey, more felt comfortable managing stress urinary incontinence (SUI) and overactive bladder (OAB), compared with pelvic organ prolapse (POP) and faecal incontinence (FI) and were less likely to refer patients with urinary symptoms. Few providers elicited symptoms for POP and FI as compared with SUI and OAB. Provider variables that were significantly associated with discomfort with management varied by PFD, but tended to correlate with less exposure to PFDs (eg, those with fewer years of practice, and internal medicine and family physicians as compared with geriatricians); whereas the factors that were significantly associated with difficulty in referral, again varied by PFD, but were related to practice characteristics (eg, specialist network, type of practice, practice setting and quantity of patients). CONCLUSION: These findings highlight the need to increase PCPs awareness of PFDs and develop effective standardised screening protocols, as well as collaboration with pelvic floor specialists to improve screening, treatment and referral for patients with PFDs.

Return to Baseline Functional Status in Older Women Undergoing Surgery for Pelvic Organ Prolapse.

OBJECTIVE: The aim of the study was to determine the rate of return to baseline functional status 3 months after surgery for pelvic organ prolapse (POP) in women 65 years or older. METHODS: This is a multicenter prospective cohort study of women older than 65 years undergoing POP surgery. Functional status was determined by the Activities Assessment Scale at the preoperative visit and 3 months after surgery. We compared a variety of clinical variables and preoperative functional status scores for women who worsened, improved, or returned to baseline functional status after surgery using univariable and multivariable analysis. RESULTS: A total of 192 women were enrolled in the study. Of 176 women who completed both sets of questionnaires, 59% improved, 35% returned, and 6% worsened from their baseline functional status. Variables significantly associated with postoperative functional status score were depression (P < 0.002) and preoperative functional status score (P < 0.001). The group that improved from baseline had the lowest (worst) preoperative functional status score (78.7 ± 16.4), whereas the group that worsened after surgery had the highest (best) preoperative functional status score (98.6 ± 2.2). After adjusting for age and depression, higher preoperative functional status score was predictive of failure to return to baseline functional status. CONCLUSIONS: Most older women undergoing surgery for POP, including those with low preoperative functional status, return to or improve from their baseline functional status within 3 months of surgery. Women with higher functional status before surgery are less likely to report improvement in physical functioning after surgery.

Urinary Incontinence and Pelvic Organ Prolapse Knowledge, Care-Seeking, and Embarrassment in Women Planning Bariatric Surgery: A Cross-sectional Study.

OBJECTIVE: The objective of this study was to assess whether patients seeking bariatric surgery were at least as proficient in urinary incontinence (UI) and pelvic organ prolapse (POP) knowledge as the general population. Our secondary objective was to determine care-seeking and impact of embarrassment on knowledge of pelvic floor disorders (PFDs). METHODS: An anonymous survey was administered to adult women who attended a bariatric surgery information session from May 2015 to January 2016. The comprehensive survey included multiple data points and the Prolapse and Incontinence Knowledge Quiz. The study population was compared with a general population described in a previously published study. RESULTS: Three hundred fifteen participants completed the survey (88% response rate). Mean ± SD age was 41.1 ± 11.3 years (range, 18-69 years), and mean body mass index was 47.4 ± 9.6 kg/m (range, 26.7-104.5 kg/m). A total of 196 women (62.2%) had at least one bothersome PFD symptom. The study population was at least as proficient in UI knowledge as the general population (P < 0.0001), but not for POP knowledge (P < 0.946). Among participants with symptomatic PFD, 91.7% of those with UI symptoms and 70% of those with POP symptoms reported that they would seek care. There was a difference in knowledge proficiency between women who were and were not embarrassed to discuss UI (P = 0.77) or POP (P = 0.99). CONCLUSIONS: The study population demonstrated less POP knowledge than the general population, but not for UI knowledge. A high proportion of women with UI or POP symptoms would seek care, but embarrassment to discuss UI or POP negatively impacted knowledge.

Patient satisfaction and informed consent for surgery.

BACKGROUND: Informed consent is a process that necessitates time and effort. Underlying this investment is the belief that informing patients about the surgery promotes patient satisfaction with the decision for surgery and potentially satisfaction more broadly. OBJECTIVE: The objective of the study was to investigate the extent to which preoperative satisfaction with a decision to pursue surgery is associated with understanding after an informed consent discussion. STUDY DESIGN: We performed an observational study of adult women seeking surgical treatment for pelvic floor disorders. Study participants were recruited after routine preoperative counseling by board-certified or board-eligible urogynecologists. In our practice, the preoperative informed consent process typically includes a discussion of the indications, risks, benefits, alternatives, and chance of success of the procedures. Participants completed a 35 question survey preoperatively at one setting. The primary outcome, satisfaction with decision, was measured with a validated 6 item Satisfaction with Decision Scale-Pelvic Floor Disorder. Participants were classified as highly satisfied if they indicated the highest level of satisfaction for all items. The primary exposure was patient knowledge of the planned surgery, measured using a newly adapted 20 item Informed Consent Questionnaire including 15 yes/no questions and 5 free-text questions. Additionally, the survey included a validated 3 item tool for health literacy, a single-item anxiety measure, and demographic data. Analyses were performed with a χ2 test, a Student t test, and a multivariable logistic regression using the binary outcome variable, highly satisfied or not highly satisfied. RESULTS: A total of 150 participants were enrolled, with a mean age of 57.5 years. The majority were non-Hispanic (97.3%) or white (87.3%), with at least some college education (51.0%). The median number of days between the informed consent discussion and the survey was 35. The mean total Satisfaction with Decision score was 27.9 (SD, 2.6; range, 19-30), indicating overall high satisfaction with the decision. A patient's preoperative satisfaction with her decision was strongly associated with increased knowledge of the planned surgery, as measured on the Informed Consent Questionnaire (P = .003). The mean score for the highly satisfied group was 17.8 (n = 70; SD, 3.6; range, 6-20) and for the not highly satisfied group was 16.1 (n = 77; SD, 2.8; range, 9-20). There were no significant differences between the highly satisfied and not highly satisfied groups with respect to age, race, education level, anxiety score, or health literacy. The odds of being highly satisfied increased for every 1 point increase in the Informed Consent Questionnaire score (odds ratio, 1.28; 95% confidence interval, 1.06-1.32; P = .003). The association between decisional satisfaction and knowledge persisted after controlling for demographic and clinical variables including education level, health literacy, race/ethnicity, age, surgeon years since completing fellowship, diagnosis, surgery category, number of visits in the past 6 months, and number of days between informed consent discussion and survey. CONCLUSION: This study found that patient knowledge and understanding of surgery are important components of a patient's satisfaction with her decision to proceed with pelvic floor surgery. By measuring patient understanding after informed consent discussions, clinicians may be able to better manage preoperative expectations, increase patient satisfaction, and improve the informed consent process.

The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update.

Using a lifespan model, this article presents new scientific findings regarding risk factors for pelvic floor disorders (PFDs), focusing on the role of childbirth in the development of single or multiple coexisting PFDs. Phase I of the model includes predisposing factors, such as genetic predisposition and race. Phase II includes inciting factors, such as obstetric events. Prolapse, urinary incontinence (UI), and fecal incontinence (FI) are more common among vaginally parous women, although the impact of vaginal delivery on risk of FI is less dramatic than prolapse and UI. Phase III includes intervening factors, such as age and obesity.

Cost utility analysis of urethral bulking agents versus midurethral sling in stress urinary incontinence.

OBJECTIVE: The aim of this study was to determine the cost utility of urethral bulking agents (BA) compared with midurethral slings (MUS) in the treatment of stress urinary incontinence (SUI) in patients without urethral hypermobility. METHODS: A decision tree was constructed to compare the cost utility of urethral BA versus MUS in the setting of SUI without urethral hypermobility. Probability estimates for success, failure, and complications were obtained from the published literature. Immediate-term, short-term, and longer-term complications were accounted for over a 1-year time horizon in the model. One-way and 2-way sensitivity analyses and Monte Carlo simulations were performed to assess the robustness of our results. RESULTS: Our model demonstrated that MUS cost $436,465 more than BA for every 100 women treated in 1 year. Using MUS compared with BA leads to an incremental cost-effectiveness ratio of $70,400 per utility gained. Assuming a willingness to pay of $50,000, this makes MUS not cost-effective as a first-line treatment in many situations. When MUS costs less than $5132, it becomes a cost-effective first-line treatment, and when it costs less than $2035, it is cost saving. CONCLUSIONS: Bulking agents are more cost-effective than MUS over a 1-year time horizon in the treatment of SUI in patients without urethral hypermobility. In women who lack urethral hypermobility, BA remain a cost-effective option in this patient population.

Longitudinal changes in pelvic organ support among parous women.

OBJECTIVE: The objective of this study was to characterize changes in pelvic organ support and symptoms of prolapse over time and identify characteristics associated with worsening of support. METHODS: Participants were recruited based on the mode of delivery (cesarean vs vaginal delivery) of their first child. The Pelvic Organ Prolapse Quantification system was used to describe support at baseline and 12 to 18 months later. Symptoms were assessed using a validated questionnaire. Outcomes of interest included the proportion of women with a change in support greater than 1 cm at the anterior vaginal wall (Ba) or posterior vaginal wall (Bp) and a change in support greater than 2 cm at the apex (C). Characteristics associated with worsening of support were identified using 2-sided Fisher's exact test and multivariable logistic regression. RESULTS: Among 749 participants, 60% had delivered by cesarean delivery only. Worsening support at Ba, Bp, and C was observed in 8%, 2%, and 6%, respectively. Worsening at any point was observed in 110 women (15%). Women with prolapse symptoms at baseline were not more likely to experience worsening of support. In a multivariable model, age older than 40 years (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.09-2.49), vaginal delivery (OR, 3.12; 95% CI, 1.38-7.07), and genital hiatus greater than or equal to 2 (OR, 2.36; 95% CI, 1.03-5.43) were all associated with worsening support in at least 1 compartment. CONCLUSIONS: Over 12 to 18 months, characteristics most strongly associated with worsening of pelvic support include genital hiatus size, vaginal birth, and age.

Short-chain fatty acid-mediated effects on erythropoiesis in primary definitive erythroid cells.

Short-chain fatty acids (SCFAs; butyrate and propionate) up-regulate embryonic/fetal globin gene expression through unclear mechanisms. In a murine model of definitive erythropoiesis, SCFAs increased embryonic beta-type globin gene expression in primary erythroid fetal liver cells (eFLCs) after 72 hours in culture, from 1.7% (+/- 1.2%) of total beta-globin gene expression at day 0 to 4.9% (+/- 2.2%) in propionate and 5.4% (+/- 3.4%) in butyrate; this effect was greater in butyrate plus insulin/erythropoietin (BIE), at 19.5% (+/- 8.3%) compared with 0.1% (+/- 0.1%) in ins/EPO alone (P < .05). Fetal gamma-globin gene expression was increased in human transgene-containing eFLCs, to 35.9% (+/- 7.0%) in BIE compared with 4.4% (+/- 4.2%) in ins/EPO only (P < .05). Embryonic globin gene expression was detectable in 11 of 15 single eFLCs treated with BIE, but in0 of 15 ins/EPO-only treated cells. Butyrate-treated [65.5% (+/- 9.9%)] and 77.5% (+/- 4.0%) propionate-treated eFLCs were highly differentiated in culture, compared with 21.5% (+/- 3.5%) in ins/EPO (P < .005). Importantly, signaling intermediaries, previously implicated in induced embryonic/fetal globin gene expression (STAT5, p42/44, and p38), were not differentially activated by SCFAs in eFLCs; but increased bulk histone (H3) acetylation was seen in SCFA-treated eFLCs. SCFAs induce embryonic globin gene expression in eFLCS, which are a useful short-term and physiologic primary cell model of embryonic/fetal globin gene induction during definitive erythropoiesis.