Anal sphincter repair for fecal incontinence: effect on symptom severity, quality of life, and anal sphincter squeeze pressures.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to determine the effect of external anal sphincter repair on fecal incontinence symptoms, quality of life, and anal sphincter squeeze pressures. METHODS: The fecal incontinence symptoms and impact on quality of life, patient satisfaction, and anorectal manometry were assessed pre- and post-operatively. RESULTS: One hundred four women were eligible and 74/104 (71%) returned post-operative questionnaires. Fifty-four of 74 (73%) had pre- and post-operative questionnaires. Twenty-five of 74 (34%) had pre- and post-operative anorectal manometry measures. Mean length of follow-up for participants (n = 54) was 32 ± 19 months. Modified Manchester Health Questionnaire scores decreased from 47.3 ± 21.9 to 28.4 ± 24.3 (p < 0.01) and Fecal Incontinence Severity Index scores from 30.6 ± 13.0 to 21.6 ± 15.5 (p < 0.01). Seventy-seven percent of the participants was satisfied. Sphincter squeeze pressures increased from 53.4 ± 25.0 to 71.8 ± 29.1 mmHg (p < 0.01). CONCLUSIONS: External anal sphincter repair resulted in sustained improvements in fecal incontinence severity and quality of life along with improved anal sphincter squeeze pressures.

Factors Influencing Post-Operative Short-Term Outcomes of Vesicovaginal Fistula Repairs in a Community Hospital in Liberia.

OBJECTIVES: To assess factors influencing short-term outcomes of vesicovaginal fistula (VVF) repairs in community-dwelling women of Liberia, Africa. METHODS: Forty patients who underwent VVF repairs were analyzed. Primary outcome was continence status at 14 days post repair. Factors influencing continence status were characterized. RESULTS: The mean duration of leakage was 9.6 ± 8.3 years, (3 months-28 years). Thirteen (33%) had previous repairs, and 6 (15%) had multiple fistula sites. Twenty-eight (70%) were continent at catheter removal. First time repairs had a higher continence rate compared to women with previous repairs, 78% and 54% respectively (p= 0.15). Seven (47%) juxtaurethral repairs were considered failures, while only one (9%) juxtacervical fistulas remained incontinent (p= 0.069). Controlling for duration of leakage, women with previous repairs were significantly less likely to be continent (p = 0.04; adjusted OR = 0.07; 95% CI: 0.005, 0.83). CONCLUSIONS: Patients with previous VVF repairs and juxtaurethral fistulae experience lower success rates; surgery remains an effective treatment for many VVF patients.

Obliterative vaginal surgery for pelvic organ prolapse.

Obliterative vaginal surgery is an appropriate management option for pelvic organ prolapse in women who do not desire future vaginal intercourse. When colpoclesis is not technically feasible, constricting repairs can be performed. Obliterative surgery in older women has the advantages of fewer complications and less surgical time than reconstructive procedures, especially in those with medical comorbidities. Age-related changes in physiology should be kept in mind along with the risk of postoperative delirium. Candidates should be counseled regarding high success and satisfaction rates.

Synthetic graft use in vaginal prolapse surgery: objective and subjective outcomes.

INTRODUCTION AND HYPOTHESIS: This study reports 1-year outcomes in women who underwent transvaginal pelvic organ prolapse (POP) surgery with Prolift transvaginal mesh. METHODS: Pre- and postoperative objective vaginal Pelvic Organ Prolapse Quantification (POP-Q) and subjective symptom and impact assessments (Pelvic Floor Distress Inventory (PFDI)-20 and Pelvic Floor Impact Questionnaire (PFIQ)-7, respectively) were performed. Postoperative vaginal tenderness, stricture, and patient satisfaction were also obtained. Paired t tests were utilized for analysis. RESULTS: Mean age was 61.8 +/- 9.8 years; mean follow-up interval was 425.0 +/- 80.0 days (range, 237-717). POP-Q measurements of Ba, Bp, and C were significantly improved (all p values

Pharmacologic management of the older woman undergoing surgery.

Surgical intervention for both emergency and elective surgeries will increase as women live longer and maintain active lifestyles. Older women with operable conditions tolerate elective gynecologic and other nonvascular surgery with acceptable morbidity and mortality. However, increased medical comorbidities, with their associated increase in polypharmacy and perioperative risks as women age, make it important to a priori optimize perioperative medical conditions and medication management. Other considerations include assessing functional and cognitive status, since these may be impaired acutely with increased prevalence of drug use during surgical hospitalization. With aging and postmenopausal status, changes associated with aging appear to play a greater role than gender in pharmacologic responses. Surgical outcomes should be optimized to maintain and even improve women's quality of life.

Pilot study utilizing a patient educational brochure at a vesicovaginal fistula hospital in Nigeria, Africa.

This paper presents a pilot study exploring the utility and feasibility of use of a vesicovaginal fistula (VVF) patient educational brochure. Women awaiting or recently having undergone VVF surgery examined a six-paneled educational brochure detailing the causes, treatment options, and prevention methods of VVF. Participants answered demographic questions and gave detailed responses to a questionnaire that addressed the brochure material. A convenience sample of 50 patients, with a mean age of 26.1 years, participated. Universally, these women felt that the information they learned from the brochure was useful. Suggestions by participants regarding prevention of VVF included laboring in a hospital (80%), educating other women (30%), and discouraging early marriage (8%). Primary barriers to prevention and treatment included financial restraints (84%) and transportation difficulties (30%). The utilization of a simple, low-cost educational brochure has the ability to educate women on the causes, treatment, and prevention of VVF.

Sphincter tears in primiparous women: is age a factor?

Anal sphincter tears during vaginal delivery may result in serious sequelae. We examined whether younger primiparous patients were at increased risk for sphincter tears during vaginal delivery. Data from an obstetric automated record were analyzed. Primiparous women delivering term infants (n = 5,937) were included to test for an association between age and sphincter tear rates. Three age groups were considered: young adolescents (≤ 16 years), older adolescents (17-20 years), and adults (≥ 21 years). No significant difference was found in tear rates among age cohorts (9.2%, 8.0%, and 9.6% respectively; p = 0.12). Logistic regression modeling revealed that young adolescents were not more likely to have sphincter tears compared to older cohorts. Younger adolescents may not be at increased risk of anal sphincter tears. Decisions regarding interventions to decrease sphincter tears during vaginal delivery should not be made on the basis of maternal age alone.

Prolapse and incontinence surgery in older women.

PURPOSE: Pelvic floor disorders including urinary incontinence, pelvic organ prolapse and fecal incontinence are common problems encountered by the older woman. With the increasing population of older American women urologists and gynecologists can expect to provide evaluation and treatment of these conditions with increasing frequency. These conditions are amenable to medical and surgical therapies. MATERIALS AND METHODS: Contemporary articles (2003 to the present) that included older women undergoing urogynecological surgery were included in this review. Current data on morbidity, mortality and/or surgical outcomes are presented with evidence based preoperative, intraoperative and postoperative surgical management strategies. RESULTS: Older women undergoing pelvic floor surgery can expect operative risks as well as subjective and objective anatomical and quality-of-life outcomes similar to those of younger women. CONCLUSIONS: The decision for surgical intervention for the treatment of pelvic floor disorders should not be based on chronological age alone. Before selecting a specific surgical procedure, all existing pelvic floor defects should be evaluated. Further research is required to understand the impact that surgery for pelvic floor disorders has on anatomical, physiological and functional outcomes in older women.

Diffuse endometritis in the setting of umbilical endometriosis: a case report.

BACKGROUND: Umbilical endometriosis is rare and can be a challenging diagnosis in the absence of classic signs and symptoms. CASE: A case of severe, primary, spontaneous umbilical endometriosis with foci of plasma cell endometritis and diffuse stromal lymphovascular presence occurred. CONCLUSION: Despite a lengthy differential, endometriosis must be considered in the evaluation of an umbilical mass. The presence of plasma cell endometritis and stromal lymphovascular elements in the absence of pelvic endometriosis lends evidence to the theory of lymphovascular transport as an etiology of extrapelvic endometriosis.

Intraabdominal pressure changes associated with lifting: implications for postoperative activity restrictions.

OBJECTIVE: The purpose of this study was to describe the effect of the lifting maneuver and the quantity of weight lifted on the generation of intraabdominal pressure. STUDY DESIGN: Forty-one women who underwent urodynamic evaluation performed 4 lifting maneuvers, each while lifting 0, 2.5, 5, 10, and 15 kg. The lifting maneuvers were routine activities that included squatting with and without assistance, lifting from a counter, and receiving weight. Pressure was recorded with a rectal microtip catheter. Each lift was performed twice, and the average pressure change was analyzed. RESULTS: When controlled for potential confounding variables, repeated-measures analysis of variance revealed a significant interaction between lift weight and lift maneuver (P < .001). Squatting was associated with generation of higher intraabdominal pressure than lifting from a counter or receiving weights into outstretched arms (P < .001). Lifting > or = 2.5 kg resulted in significant changes in intraabdominal pressure, regardless of lift maneuver (P < .001). CONCLUSION: Both the lifting maneuver and the quantity of weight should be considered when counseling patients regarding postoperative lifting.

A modified Mainz II pouch technique for management of refractory vesicovaginal fistulas: patient focused outcomes.

OBJECTIVE: To follow-up the quality of life outcomes in 2 women who underwent a modified Mainz II pouch procedure for refractory vesicovaginal fistulas. METHOD: Two Nigerian patients were located after undergoing a modified Mainz II pouch procedure. They were interviewed 1-2 years postprocedure regarding subsequent sexual function, pregnancy outcomes, and daily life. RESULT: After undergoing the procedure the patients had resumed sexual function, had become pregnant, and had delivered viable neonates. They were also able to provide for their families. CONCLUSION: A urinary diversion procedure for management of refractory vesicovaginal fistula can restore quality of life.

Impact of urinary incontinence in morbidly obese women versus women seeking urogynecologic care.

OBJECTIVES: To determine the impact of urinary incontinence (UI) on quality of life in morbidly obese women seeking bariatric surgery compared with women seeking urogynecologic care. METHODS: Women undergoing consultation for weight loss surgery completed questionnaires assessing the presence and severity of UI using the Medical, Epidemiological, and Social Aspects of Aging questionnaire and the impact of their UI using the Incontinence Impact Questionnaire-7 and Urogenital Distress Inventory-6. The charts of the women with UI seen in a urogynecology center were reviewed. For these two samples, pairs were matched for UI severity using the total Medical, Epidemiological, and Social Aspects of Aging scores, and the women within pairs were compared concerning the impact of UI. RESULTS: A total of 93 pairs were matched. Morbidly obese women had lower scores on the Incontinence Impact Questionnaire-7 (mean 20.1 versus 42.0, P <0.0001) and the Urogenital Distress Inventory-6 (mean 30.4 versus 54.4, P <0.0001) compared with the urogynecology clinic patients. CONCLUSIONS: The results of our study have shown that the impact of UI is lower in morbidly obese women than in women seeking urogynecologic care.

Optimizing outcomes of surgery in advanced age--perioperative factors to consider.

The gynecologic surgeon should be knowledgeable about the normal physiologic changes associated with aging and skilled at assessing baseline medical comorbidities, neuropsychiatric, nutritional, social, and functional status as increasing numbers of older women seek and undergo surgical interventions to improve their quality of life. A multidisciplinary approach to the perioperative care of the older woman, aiming for prevention and early intervention, can help minimize both typical surgical complications and "geriatric" complications.

Pelvic floor surgery in the older woman.

Pelvic floor disorders including urinary incontinence, pelvic organ prolapse, and fecal incontinence are common problems encountered by the older woman. With the increasing population of older Americans, healthcare providers can expect to provide evaluation and treatment of these conditions with increasing frequency. These conditions are amenable to both medical and surgical therapies. The older woman who undergoes surgery can expect similar risks and outcomes to that of younger women. Further research is required to more fully understand the functional, anatomic, and physiologic outcomes after treatment for pelvic floor disorders in the older woman.

Outcomes of vaginal vault prolapse repair with a high uterosacral suspension procedure utilizing bilateral single sutures.

The aim of this study was to describe an approach for performing a high uterosacral vaginal vault suspension and to report anatomical and subjective results. Anatomic measures and validated symptom-specific questionnaires were performed pre- and postoperatively. Patient satisfaction was also ascertained. Thirty-five women, who underwent a two-suture high uterosacral suspension, participated. Mean follow-up interval was 23.1+/-10.1 months. Postoperative point C was -7.8+/-1.60 (median, -8.0, range, -4.0 to -10.0), and the mean preoperative to postoperative change in point C was 5.9+/-5.56 cm (median 4.75, range -3.0 to 20.0, p-value<0.0001). Patient satisfaction was high with 88.9% indicating that they would have the surgery again. There were no ureteral injuries or kinks noted on intraoperative cystoscopy. No patient required reoperation for recurrent prolapse or urinary incontinence. Overall, the two-suture high uterosacral vaginal vault suspension is an acceptable technique for repairing apical prolapse.