Body image in the Pelvic Organ Prolapse Questionnaire: development and validation.

OBJECTIVE: The purpose of this study was to develop and validate a prolapse-specific body image questionnaire. STUDY DESIGN: Prolapse-specific body image themes that were identified in our previous work served as a framework for the development of a question pool. After review for face and content validity and reading level, the question pool was reduced to 21 items that represent predominant themes and that form the initial Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire. Women with symptomatic prolapse of Pelvic Organ Prolapse Quantification (POPQ) of more than stage II were enrolled from 2 academic urogynecology practices; they completed questionnaires on pelvic floor symptoms and distress, general body image, depression, self-esteem, and the BIPOP questionnaire, and they underwent the POPQ. We field-tested the BIPOP questionnaire with approximately 200 participants; 10 women completed cognitive interviews, and 100 women repeated the BIPOP questionnaire to assess test-retest reliability. RESULTS: Two hundred eleven participants were enrolled, and 201 women had complete data. Participants had mean age of 60.2 ± 10.5 years, were predominantly white (98%), were partnered (80%), and had median POPQ stage III. Cognitive interviews confirmed comprehension and clarity of questions and acceptability of length and subject matter. Exploratory factor analysis was performed in an iterative process until a parsimonious, 10-item scale with 2 subscales was identified (subscale 1 represented general attractiveness; subscale 2 represented partner-related prolapse reactions). Cronbach's α score for the subscales were 0.90 (partner) and 0.92 (attractiveness). Correlations between related questionnaires and BIPOP subscales were strong and directionally appropriate. Test-retest correlations on both total and subscale measurements were high. CONCLUSION: We developed and validated a prolapse-specific body image measurement that has face and content validity, high internal consistency, strong correlation with general prolapse and body image measures, and strong test-retest reliability.

Should endocervical curettage routinely be performed at the time of colposcopy? A cost-effectiveness analysis.

OBJECTIVES: Endocervical curettage (ECC) has been used with colposcopy-directed biopsy to increase diagnostic sensitivity for detecting cellular abnormality. Our objective was to determine if routine ECC was cost-effective compared with colposcopy alone in women with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion cervical cytology, who are older and younger than 50 years. MATERIALS AND METHODS: We generated a cost-effectiveness model using outcomes from cervical screening including repeat Pap smears, colposcopy, and loop electrosurgical excision procedure. Cervical cancer costs, survival, as well as incidence and complications after loop electrosurgical excision procedure (preterm birth, cervical stenosis, dysmenorrhea, amenorrhea, and infertility) were modeled. Cost and probability values were obtained from published literature and Medicare databases. Direct medical costs were analyzed in 2011 US dollars. Effectiveness outcomes were cervical cancer deaths and incident cases of cancer prevented. Model robustness was evaluated using probabilistic sensitivity analysis. RESULTS: For women older than 50 years, routine ECC is the dominant strategy (less expensive and more effective at reducing cervical cancer deaths/incidence). For women younger than 50 years, routine ECC costs $96,737 more per cervical cancer death prevented. Cost per incident cancer case prevented ranged from $21,894 (local spread or greater) to $235,873 (distal spread). Sensitivity analysis confirmed these conclusions. In women older than 50 years, routine ECC was always the most likely cost-effective choice. In women younger than 50, routine ECC was most likely cost-effective for all willingness-to-pay thresholds greater than $80,000 to prevent 1 cancer death. CONCLUSIONS: In women older than 50 years, routine ECC is favored over colposcopy alone because this strategy is cost saving and reduces the number of cancer deaths and incident cancer cases. For women younger than 50 years, cost-effectiveness is dependent on willingness to pay to prevent 1 cancer death but still seems to be cost-effective.

InterStim Sacral Neuromodulation and Botox Botulinum-A Toxin Intradetrusor Injections for Refractory Urge Urinary Incontinence: A Decision Analysis Comparing Outcomes Including Efficacy and Complications.

OBJECTIVE: : Overactive bladder is a common disease for which current pharmaceutical therapy is often unsatisfactory. Newer modalities, including Botox and InterStim, can be used when antimuscarinics fail. We compare InterStim and Botox using decision analysis. METHODS: : A Markov state transition decision analysis model was constructed using values for efficacy and complications from the literature. Overall utility was compared monthly. Multiple 1-way sensitivity analyses were performed. RESULTS: : For every month during the simulation, overall utility was higher for Botox than InterStim. After 54 months, cumulative utility was 3.86 versus 3.74, favoring Botox for an average yearly quality-adjusted life-year value of 0.86 versus 0.83. All differences were less than minimally important differences for utilities. Few meaningful thresholds were established supporting the robustness of the model. CONCLUSIONS: : Until appropriately powered randomized controlled trials are available, both InterStim and Botox are reasonable and effective strategies with similar outcomes.

Pelvic support and urinary function improve in women after surgically induced weight reduction.

OBJECTIVE: : The objective of this study was to assess pelvic organ support and symptoms in morbidly obese women before and after weight reductive surgery. METHODS: : Fifty-four women were enrolled in this institutional review board-approved protocol. Data collection at baseline and 6 months following surgery included a Pelvic Organ Prolapse Quantification examination, questionnaires including the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, and the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire short form, and a 3-day voiding diary. Before-surgery and after-surgery measures were compared using paired Student t tests for continuous, normally distributed data or the Wilcoxon signed rank test for ordinal data. RESULTS: : Baseline and 6-month data were available for 34 women. The mean body mass index was 46 ± 6 kg/m at baseline and 33 ± 6 kg/m after 6 months. Subjects with ≥stage 2 prolapse at baseline demonstrated an improvement of 0.5 cm (baseline, 0.9 ± 0.8 cm; after 6 months, -1.4 ± 0.9 cm) in the anterior vaginal compartment (points Aa/Ba) 6 months following weight reductive surgery (P = 0.05). Of 24 women who completed 3-day voiding diaries, 12 were incontinent at baseline with a median number of incontinent episodes of 6.5 per day (range, 3-34). After surgery, 6 incontinent women became continent. In the 6 women who remained incontinent after surgery, the number of incontinent episodes per day decreased by a median of 2.5 (range, 1-11). Pelvic Floor Distress Inventory scores improved following weight reduction (baseline, 115 ± 80; after 6 months, 58 ± 70; P < 0.01). DISCUSSION: : Obese women, after surgically induced weight loss, demonstrate an improvement in anterior vaginal support, urinary leakage and pelvic floor symptoms.

Normative data for commonly used validated pelvic floor disorder questionnaires in women.

OBJECTIVE: : To report measures of central tendency for Pelvic Floor Distress Inventory (PFDI), Pelvic Floor Impact Questionnaire (PFIQ), and 12-item short form Pelvic Organ Prolapse-Incontinence-Sexual Function Questionnaire (PISQ-12) in women with POPQ stage ≤I. METHODS: : An analysis was conducted of 67 women participating as controls in a body image in prolapse study who were recruited from a general gynecology setting. Following are the inclusion criteria: (1) presenting complaint was not prolapse/incontinence symptoms; (2) answered "no" to questions, (a) "Do you usually have a sensation of bulging protrusion from the vaginal area?" and (b) "Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?" (3) POPQ stage ≤I; and (4) no prior surgery for prolapse/incontinence. Descriptive statistics were calculated for PISQ-12 and long and short forms of PFDI and PFIQ. RESULTS: : Subjects had a mean age of 54 ± 8 years and a median of POPQ stage I. Median total and subscale scores for long and short forms of PFDI and PFIQ were ≤15. Mean PISQ-12 was 34 ± 3. Reliability testing using Cronbach's α was performed: PFDI (α = 0.930), PFIQ (α = 0.978), and PISQ-12 (α = 0.469). CONCLUSIONS: : Knowledge of normative data for pelvic floor symptom questionnaires is important to better assess outcomes after reconstructive surgery for pelvic floor disorders.